Conventional Hysteroscopy Research Articles

Office Vaginoscopic Hysteroscopy in Infertile Women: Effects of Gynecologist Experience, Instrument Size, and Distention Medium on Patient Discomfort

Study Objective To assess the roles of instrument diameter (5.0- or 3.5-mm external sheath), uterine distention medium (carbon dioxide [CO 2] or saline solution), and hysteroscopist experience in diagnostic hysteroscopy. Design Prospective, randomized, multicenter trial (Canadian Task Force classification I). Setting Two university medical centers in Italy. Patients One hundred eighty-four women attending an infertility clinic. Interventions Patients were randomly assigned to undergo conventional hysteroscopy (group 1, n = 92) or minihysteroscopy (group 2, n = 92) with CO 2 or saline solution as distention medium. The procedures were performed by hysteroscopists with varying degrees of experience. Patient discomfort was analyzed using the visual analog score. Procedure complications and patient satisfaction rate were also recorded. Measurements and Main Results Independent of hysteroscopist experience, less pain, fewer complications, and higher satisfaction rates were observed with minihysteroscopy. In addition, procedures in which saline solution was used resulted in less pain and fewer complications than those in which CO 2 was used, but only when performed by inexperienced hysteroscopists. Conclusion Instrument diameter and hysteroscopist experience, but not the distention medium, seem to be the primary variables that affect the perception of discomfort during office hysteroscopy.

Minihysteroscopy for examination and management of pathologic lesions of virginal reproductive tracts: can we preserve the hymen intact?

Dear Editors, Hysteroscopy has been widely used for uterine cavity examination and management. Although the possibility of hymen preservation is high, virgins are highly resistant to this procedure [1]. This may be due to a belief that the procedure causes disruption of virginity and worries associated with their future partners. Case 1 was a 31-year-old virgin complaining of abnormal vaginal bleeding for months despite of medical treatment. Hysteroscopic examination was indicated, but she initially hesitated. After extensive counseling about the beneWts and limitations of both conventional hysteroscopy and minihysteroscopy, she chose a minihysteroscopy with 4-mm continuous-Xow outer sheath, 5Fr operating channel and 2-mm 0°-telescope (Karl Storz, Tuttlingen, Germany) rather than a 8-mm hysteroscopy. The procedure was conducted under intravenous sedation without use of speculum, tenaculum and cervical dilators. An operative assistant was assigned to hold the hysteroscope in place to make sure the downward pressure was not excessive and for paying attention to safety of the hymen. Additionally, avoidance of wide movements during manipulation was necessary. Vagina and cervical canal were normal; one 8-mm endometrial hyperplastic polyp was found at the posterior wall of the uterine cavity and removed by a Xexible biopsy forceps piecemeal through the channel. Case 2 was a 43-year-old virgin complaining of a vulvar mass for a long time, but she was too embarrassed to visit a gynecologist. Physical examination revealed a 6-cm erosive tumor protruding from the vagina (Fig. 1a). On minihysteroscopy, the uterine cervix was normal and the tumor growing from the left lateral vaginal wall 4 cm behind the introitus (Fig. 1b) was extracted cautiously by smallest Pean forceps. The hymen integrity was preserved (Fig. 1c), and a benign polyp was diagnosed pathologically. Operation duration for both patients was less than 20 min, and both were uneventful. Their symptoms were relieved thereafter, and they were satisWed with the procedure and outcome. Informed consent was obtained from Case 2 for use of the pictures. Hymen integrity is an important representation of virginity in some countries even though it is not absolutely related to virginity. When a reproductive tract examination or transvaginal operation must be arranged for a virgin, the operator faces a challenge and may hesitate to utilize hysteroscopy, which can result in a delayed diagnosis or improper treatment. The most common indication for hysteroscopy was abnormal vaginal bleeding, experienced by 52.5% of 40 virginal patients [1, 2]. The acceptance rate for surgery, however, was only 78% [1]. Hymen integrity was preserved in all reported cases without major complications. Our Wndings concurred with their results. So far, only a few reports have discussed the protection of hymen integrity in hysteroscopy [1, 2], and the physical and psychological impacts of this surgery in virgins are not conclusive. Although hysteroscopy can improve diagnosis and thereby improve quality of life, virgins may decline this procedure. Patients with delayed diagnosis and management in some uncommon but serious situations, such as endometrial malignancy, are life-threatening. This is an important issue that gynecologists encounter, but which has seldom been discussed. In the two cases described above, minihysteroscopy was able to fulWll their physical and psychological needs after endometrial polypectomy or vaginal tumor removal. M.-L. Cheong (&) Department of Obstetrics and Gynecology, Cathay General Hospital, #280, Sect. 4, Jen-Ai Road, Taipei 106, Taiwan e-mail: joymlcheong@gmail.com

Modern endoscopic-based exploration of the female reproductive tract: a model for developing countries?

Infertility has been notorious for its time-consuming and prolonged explorations and the resultant delay in diagnosis. This delayed diagnosis adds to the burden of the patient and, in spite of the higher pregnancy rate and lower cost reported with traditional treatment algorithm as first-line therapy compared with liberal referral to assisted reproduction technologies (ART) (Karande et al., 1999), has stimulated physicians and specialized centres to promote the latest approach. This strategy has the additional problem, especially for developing countries, that ART carry a higher risk of neonatal and maternal morbidity than natural conception, even in the absence of multiple pregnancy (Helmerhorst et al., 2004; Ombelet et al., 2005, 2006). Recent observations demonstrate that exploration of the female reproductive tract is not only useful for diagnosis and treatment but also necessary for enhancing the in vitro fertilization—embryo transfer (IVF-ET) results. Indeed, a Cochrane review including three RCT shows that laparoscopic salpingectomy prior to IVF-ET in patients with hydrosalpinges improves pregnancy, ongoing pregnancy and live birth rates (Johnson et al., 2002). Furthermore, the incremental cost of the surgical intervention to achieve this higher live birth rate was reported to be beneficial (Strandell et al., 2005). Everybody agree on the value of an accurate exploration of the female reproductive tract for the management of infertility but opinions greatly differ as how and to which extent these investigations should be performed. In current practice hysterosalpingography (HSG) is still used as a first-line investigation, although it is not a pain-free (Tur-Kaspa et al., 1998) and riskfree procedure and even when its sensitivity, specificity and prognostic values for the management of the infertility are debatable (Glatstein et al., 1997; Swart et al., 1995; Mol et al., 1997, 1999). This option is largely based on the absence of alternatives since endoscopic procedures (e.g. conventional laparoscopy and hysteroscopy) demanding high skills and sophisticated equipments do not fulfil the criteria of being minimally invasive, affordable and accessible. Although conventional laparoscopy is considered the gold standard for the exploration of the female reproductive tract, it is for several reasons not suitable as a first-line investigational technique. Laparoscopy is an expensive procedure requiring hospitalization, operating room and general anaesthesia, as in open abdominal surgery. The procedure is invasive and not without morbidity and mortality. Indeed, even in experienced hands the blind transabdominal access can cause major blood vessel and bowel injury (Jansen et al., 1997; Brosens et al., 2003), whereas the distension medium (i.e. CO2 pneumoperitoneum) causes discomfort and additional hazards (Molinas and Koninckx, 2000; Molinas et al., 2001; Nguyen et al., 2002; Kissler et al., 2004). Furthermore, the see-and-treat possibility of laparoscopy requires the presence of a high skilled reproductive surgeon at the diagnostic screening procedure, which is not always feasible. The exploration of the female reproductive tract should be as easy as HSG and as accurate as standard laparoscopy. No conclusive answer has been given until now, but the transvaginal ultrasound and endoscopic procedures offer probably the most efficient and accurate solution to the problem. The challenge is for both developed as developing countries identical: to find a low cost and easily accessible diagnostic procedure with operative possibilities for offering the fastest and minimal invasive lane to pregnancy. In this article we outline a challenging concept for the management of infertility in both developed and developing countries: a model based on ambulatory endoscopic techniques (i.e. modern mini-hysteroscopy and transvaginal laparoscopy) for the exploration of the female reproductive tract, describing their diagnostic and operative possibilities and limitations.

182: Mini-Hysteroscopy Findings in Women Complaining of AUB and with No Abnormality at TVE

Abnormal uterine bleeding (AUB) is the most frequent indication for specialist consultations worldwide. Transvaginal echography (TVE) and SHG are considered first line diagnostic investigation in patients with AUB. This study aimed at evaluating the value of fluid mini-hysteroscopy (MiniHys) in women in whom TVE found no abnormality. We therefore compared findings at MiniHys with that at histology, endocervical and endometrial cultures in a group of women complaining of AUB and with no evidence of pathology at TVE. Prospective study. Clinical research and academic environment. Hundred pre-menopausal patients (age range 20–46 yrs) complaining of AUB with normal uterine cavity on TVE performed in the mid proliferative phase. Women in their follicular phase underwent diagnostic fluid MiniHys using speculum, endocervical swabs and endometrial biopsy. Main outcome measures: Endometrial findings at hysteroscopy, endometrial histology, endocervical and endometrial cultures (common bacteria, mycoplasma, chlamidya). At hysteroscopy 21 cases of endocervical polyps and 12 cases of endometrial polyps were detected. All endometrial polyps were smaller than 0.5 cm. However, in 71 cases hysteroscopic signs of chronic endometritis and/or endocervicitis were found. More in detail, hyperhemia, easy bleeding, mucosal adhesions, isolated or diffuse micropolyps, stromal edema were considered as sign of inflammation. Histology confirmed the diagnosis of CE in 40 (56.3%) cases; accordingly, endometrial culture was positive in 44 (62.0%) cases whereas positive cases at endocervical culture were significantly lower (n=29, 40.8%) (Fisher exact test: P<0.05 and P<0.01, vs. histology and endometrial culture, respectively). In 29 women with no signs of CE at MiniHys histology was positive in only 1 case, endometrial and endocervical cultures in 2 and 5 cases, respectively. In about two-thirds of women complaining of AUB but with no evidence of abnormality at TVE, direct inspection of endometrial cavity by means of hysteroscopy demonstrated signs of CE. Results of histology and endometrial cultures but not endocervical cultures showed high concordance and confirmed the hysteroscopic diagnosis in about 60% of cases. The nature of remaining 40% of cases of hysteroscopic CE remains unknown. On the basis of these results and of the advantages of MiniHys with respect to conventional hysteroscopy, MiniHys should be performed in all patients complaining of AUB whatever is TVE and SHG result.

Tolerability and Cardiovascular Complications of Outpatient Diagnostic Minihysteroscopy Compared with Conventional Hysteroscopy

Study Objective To assess acceptability and cardiovascular complications of hysteroscopy performed with minihysteroscopes compared with those performed with conventional hysteroscopes. Design Prospective, randomized clinical trial (Canadian Task Force classification I). Setting Academic research center. Patients One hundred women with abnormal uterine bleeding. Interventions Hysteroscopy with a 3.5-mm minihysteroscope or conventional 5-mm endoscope with no anesthesia. Measurements and Main Results Duration of examinations, pain, and occurrence of vasovagal reactions were recorded. Pain was assessed by visual analog scale ranging from zero to 20 before (pain expectancy) and at the end of the procedure. Occurrence of vasovagal reactions was assessed by monitoring blood pressure and pulse rate at 1-minute intervals during the procedure. A heart rate of less than 60/minute or a reduction greater than 20% compared with baseline was considered a vasovagal reaction; similarly, a reduction in blood pressure exceeding baseline value by 20% was considered a result of vagal stimulation. Mean duration was shorter for minihysteroscopy than for conventional hysteroscopy. The mean (SD) level of pain experienced during minihysteroscopy also was significantly lower (0.76 ± 0.65 vs 1.46 ± 0.86, 95% CI -1.0–0.4, p <0.0001). The number of instrumentally recorded (1 vs 11 cases) and clinical vasovagal reactions (0 vs 6 cases) was also significantly lower in the minihysteroscopy group than in the conventional hysteroscopy group (p <0.002 and <0.02, respectively). Conclusion New-generation minihysteroscopes make hysteroscopy easier and less painful, and carry a lower risk of vasovagal reactions than hysteroscopy performed with conventional instruments. In our experience, minihysteroscopy with vaginoscopic approach and saline distention is well tolerated, effective, and a true outpatient procedure.

Transcervical access and intra-luminal imaging of the Fallopian tube in the non-anaesthetized patient; Preliminary results using a new technique for Fallopian access

A study was performed to evaluate a new transcervical, Fallopian tube access system for use in falloposcopy procedures without the need for conventional hysteroscopy or uterine distension. Visualization was accomplished by the use of a 0.5 mm falloposcope which was delivered to the Fallopian tube by a new linear everting catheter. The linear everting catheter allows access to the Fallopian tube by means of a flexible, tubular rolling membrane which can safely negotiate the tortuous anatomy from the ostium to the ampulla. Concurrent laparoscopy was performed solely for supervision purposes and not for tubal manipulations in 13 Fallopian tube access procedures in 10 patients. The ostia were visualized in 12 cases and the Fallopian tube was accessed in all 12 without complications. As a precursor for future gamete and embryo transfer procedures, intra-tubal insemination was performed by visualizing the ostia, accessing the Fallopian tubes, and obtaining successful isthmic-ampullary, intra-luminal images.