Diagnostic Hysteroscopy Research Articles

Impact of uterine cavity filling pressure levels on pain and procedure duration in diagnostic hysteroscopy: A retrospective cohort study.

This study investigates the impact of intracavitary pressure levels on pain, visualization quality, and procedure duration in office hysteroscopy, comparing standard pressures (60-100 mmHg) with high pressures (110-150 mmHg). We conducted a retrospective cohort study involving non-menopausal women undergoing diagnostic hysteroscopy at a tertiary clinic. Patients were categorized into two groups based on intracavitary pressure: the standard pressure group (60-100 mmHg; n = 72) and the high-pressure group (110-150 mmHg; n = 37). Outcomes measured included pain scores, procedure duration, and fluid volume used. Logistic regression was employed to identify risk factors for severe pain. The high-pressure group demonstrated significantly shorter procedure durations compared to the standard pressure group (96.56 ± 34.36 vs. 163.00 ± 61.78 s, p < 0.001). Pain scores were lower in the high-pressure group (VAS 3.00 [0.00-7.00] vs. 3.50 [0.00-9.00], p = 0.041). Additionally, high-pressure procedures used less fluid compared to standard pressure procedures, which helps to reduce the risk of fluid-related complications. Logistic regression analysis identified higher fluid volumes (odds ratio [OR] = 1.005, 95% confidence interval [CI] = 1.001-1.010) and the need for pressure increases (OR = 3.914, 95% CI = 1.157-13.238) as significant risk factors for severe pain. Higher intracavitary pressure levels (above 100 mmHg) in office hysteroscopy are associated with reduced pain, shorter procedure durations, and decreased fluid use, enhancing visualization and procedural efficiency while maintaining patient comfort.

Justification of the necessity, value, and role of diagnostic hysteroscopy in the management plan for abnormal uterine bleeding. A teaching hospital experience

Aims: The crucial purpose of this study is to pay thoughtfulness to the filmic inspection of the uterine cavity and circumstantial operative amenities have provided the gynecologist with the perfect 'diagnostic' tool, making it conceivable to inspect the cavity and biopsy distrusted areas under direct visualization for patients presented with abnormal uterine bleeding AUB in the perimenopausal or postmenopausal periods. Materials and methods: We retrospectively reviewed the medical records of 123 perimenopausal and postmenopausal women who presented with abnormal uterine bleeding (AUB) at Jordan University Hospital (JUH) between January 1, 2022, and August 1, 2024. Participants underwent diagnostic hysteroscopy followed by endometrial biopsy. The hysteroscopic findings were compared with the final histopathological diagnoses to evaluate diagnostic accuracy. Results: In this study of 123 women, clinical indications for hysteroscopy differed by menopausal status, with heavy menstrual bleeding being the most common indication among premenopausal women (74.6%), while postmenopausal bleeding was predominant in postmenopausal women (80.8%). Hysteroscopy revealed a regular uterine cavity in 92.7% of cases, with endometrial abnormalities such as thickened or thin endometrium observed in a significant number of women. Histopathological analysis found normal endometrium in 47.2% of cases, with endometrial polyps (16.3%) and other conditions such as hormonal imbalance and endometritis also frequently noted. A significant relationship was observed between menopausal status and both uterine cavity condition (p = .025) and endometrial state (p = .002), with postmenopausal women more likely to exhibit a thin or abnormal endometrium. The diagnostic value of hysteroscopy was high for fibroids (100% detection) but lower for endometrial polyps (50% detection). Conclusion: Hysteroscopy must be used as the second-line diagnostic tool after vaginal ultrasound assessment for evaluating the endometrial status in cases of AUB and a necessary step before the decision of surgical removal of the uterus. However, hysteroscopy is not very reliable for ruling out endometrial hyperplasia or cancer in women who have postmenopausal bleeding. Because of this, an endometrial biopsy is crucial for an accurate diagnosis.

STUDY OF THE ENDOMETRIAL GLANDULAR COMPONENT IN WOMEN WITH FERTILITY AND POST-COVID SYNDROME IN ANAMNESIS

The aim. To increase the effectiveness of the endometrial endometrial glandular component study in women with infertility and post-COVID syndrome. Materials and methods. A study was conducted at the State institution "Carpathian Human Reproduction Centre" of the Ministry of Health of Ukraine in the period from 2022 to the end of the first half-year of 2024. There were included 80 women in the experimental group and 40 women in the control group. The selection criterion for the study group was the presence of documented post-COVID syndrome (COVID-19 symptoms lasted longer than 12 weeks). The selection criterion for the control group was the absence of confirmed SARS-CoV-2 virus in the anamnesis. The following characteristics were common for both groups: diagnosed infertility, age – 25-42 years, written informed consent of the patient to participate in the study. The criteria for exclusion from the study for patients of both groups were: detection of human immunodeficiency virus, viral hepatitis, other sexually transmitted infections, tuberculosis of the genitourinary system, malignant diseases, mental disorders that make communication with person impossible or the awareness of written consent is questioned. General clinical and laboratory examinations and transvaginal sonographic examination of the pelvic organs were performed in the middle stage of proliferation and the middle stage of secretion according to the calendar calculation the menstrual cycle. A visually guided diagnostic office hysteroscopy was performed with the collection of biological material from the most changed areas (biopsies were collected in the middle stage of proliferation and the middle stage of secretion in different menstrual cycles). A routine staining of samples with hematoxylin-eosin, morphometry of the endometrial glandular component, optical determination of the number of glands and measurement of the diameter of the lumen of the studied glands, considering the possible measurement error, glandular-stromal ratio, functional activity of the glands, were performed. A histochemical PAS-reaction to identify the glycoproteins of gland secretions and immunohistochemical staining of the glandular epithelium to express the receptivity of the glands to estrogen and progesterone were carried out. The results. After conducting the PAS-reaction, a higher secretion was noted in the glands than in the stroma of the endometrium during the period of the implantation window in both cohorts. No statistically significant difference between the groups in the amount of glycogen of the middle proliferative phase in the glands (p=0.315) or stroma (p=0.486). Glycogen in this phase was visualized of very small granules and coarse granules, without their formation in clusters. A decrease in secretion was established in 16 (40%) patients of the control group and 49 (61.3%) women of the experimental group in the middle secretory phase, which was statistically significant (p=0.028). A decrease in the expression level of the progesterone receptor in the middle secretory phase was found to be significantly more pronounced in the experimental group than in the control group (р=0.044). Conclusions. In the middle secretory phase, a decrease in the secretion of glycogen by the endometrial glands and a decrease in the level of expression of the progesterone receptor in endometrial biopsies were detected by the routine histological, histochemical techniques and immunohistochemical stude in women with infertility and a history of post-COVID syndrome.

Hysteroscopic Treatment of Retained Products of Conception Using See and Treat Operative Office Hysteroscopy Without Anesthesia

Study ObjectiveTo evaluate clinical efficacy of office operative hysteroscopic treatment of retained products of conception (RPOC) without anesthesia. DesignA retrospective cohort study. SettingA tertiary care academic medical center between April 2019 to March 2023. PatientsA total of 175 patients with confirmed RPOC underwent see-and-treat operative office hysteroscopy without anesthesia in our outpatient clinic. InterventionsHysteroscopic removal of RPOC without anesthesia. Measurements and Main ResultsIn 163 cases, the removal of RPOC in the office was attempted, and in 155 cases (95.1%), complete removal of the RPOC, without complications was achieved, although it sometimes required a second procedure in clinic. In 12 cases, office operative hysteroscopy was not attempted, due to physician decision based on the appearance and vascularity of RPOC, or due to pain during the diagnostic hysteroscopy, or both.The average size of RPOC for patients treated in the clinic was 15± 8.4 mm (range 4-47mm).One hundred twenty-eight cases were performed using a Truclear Elite 6mm device, and 35 cases using a mini-Bettocchi 4.2mm device.Eighteen cases were unsuccessful on the first attempt; 12 underwent a second procedure in the clinic, which was completed in 10 (83.3%) cases.105 (71.4%) patients attended a follow-up hysteroscopy, eight of them (7.6%) required separation of adhesions that was performed in the clinic, and 8 patients were referred to a surgical procedure under anesthesia, due to persistent RPOC. ConclusionOperative office hysteroscopy is feasible and highly effective for patients with RPOC, with a total success rate of 95.1% complete evacuation in clinic. A follow-up hysteroscopy is important especially after treatment of large RPOC.

The SYNAPPH Study: Uterine Synechiae Prevalence After a Postpartum Hemorrhage, a Pilot Study

Study ObjectiveTo prospectively assess the prevalence of intrauterine synechia following medically treated postpartum hemorrhage (PPH) and to evaluate the association between synechiae formation and PPH management techniques. DesignA prospective observational cohort study. SettingAngers University Hospital. ParticipantsA total of 83 women presenting with medically treated PPH from January to December 2021 were included in the study. InterventionDiagnostic hysteroscopy was performed twelve weeks postpartum to assess for the presence of uterine synechiae. Detailed data on PPH management techniques were collected for analysis. Measurements and Main ResultsThe majority of participants were primiparous and had undergone vaginal delivery. Only 7% required intrauterine balloon tamponade (IUBT), and 4% underwent uterine artery embolization. Uterine synechiae were identified in 20 women during diagnostic hysteroscopy, yielding a prevalence of 24% at 12 weeks postpartum; all classified as type I according to the ESGE classification system. IUBT was used in 15% of women with synechiae compared to 5% in the nonsynechiae group, although this difference was not statistically significant (OR 3.52, 95% CI 0.65–19.10, p = .123). Multivariate analysis identified second manual uterine examination (OR 5.00, 95% CI 1.50–16.66, p = .009) and bimanual uterine massage (OR 3.50, 95% CI 1.12–10.09, p = .020) as independent risk factors for synechiae formation. ConclusionThis is the first study to evaluate the risk of intrauterine synechiae following medically treated PPH. Mild uterine synechiae were observed in one in four women in the cohort. The need for a second manual uterine examination and bimanual uterine massage were significantly associated with the development of synechiae. Further research is warranted to explore the long-term clinical consequences, including fertility outcomes, and to determine the potential role of diagnostic hysteroscopy in postpartum follow-up after PPH. SummationThe study prospectively investigates the prevalence of uterine synechiae following nonsurgical postpartum hemorrhage, revealing a 24% occurrence, with second manual uterine examination and bimanual massage identified as independent risk factors.

Safety of diagnostic hysteroscopy for the investigation of type II endometrial cancer: systematic review with meta-analysis.

The goal of this study is to evaluate the safety of diagnostic hysteroscopy (HSC) in type II endometrial cancer (EC). We searched PubMed, the Cochrane Library and the Chinese Medical Journal Full-Text Database until December 2023. Eligible trials were all cohort studies in which patients were allocated to diagnostic HSC group or dilation and curettage (D&C) group. Quality assessments of eligible studies were performed using the Newcastle-Ottawa scales. Risk ratios (RRs) with 95% CIs were calculated as a measure of effects. Three trials were included in our analysis, which were all retrospective cohort studies. 696 patients with histologically proven type II EC were allocated to HSC or D&C before surgery. 257 patients underwent preoperative HSC, and 439 patients underwent D&C. The positive peritoneal cytology rate did not statistically differ between the groups (RR, 1.9; 95% CI, 1.00 to 3.61; p=0.05). There was no significant difference in the incidence of International Federation of Gynecology and Obstetrics (FIGO) stage between the HSC and D&C groups (stage I/II: RR, 1.08; 95% CI, 0.95 to 1.24; p=0.25; stage III/IV: RR, 0.82; 95% CI, 0.62 to 1.09; p=0.18). There was no significant difference in recurrence between the HSC and D&C groups (RR, 0.92; 95% CI, 0.66 to 1.32; p=0.66); the heterogeneity of the two included studies was acceptable (p=0.54, I2=0%). Preoperative HSC in patients with type II EC does not increase the risk for cancer cell dissemination within the peritoneal cavity. Preoperative HSC does not progress the FIGO staging in patients with type II EC and does not increase the risk of tumour recurrence. There is no reason to avoid HSC for the diagnosis of type II EC currently. However, type II tumours generally are less well differentiated and have poorer prognoses than type I tumours. More prospective and adequately powered trials are required to clarify whether preoperative HSC in patients with type II EC is safe.

Factors Associated to the Presence of Isthmocele Diagnosed by Pelvic Ultrasound, Magnetic Resonance Imaging or Diagnostic Hysteroscopy: A Cross-Sectional Study.

We aimed to analyze the prevalence of isthmocele and factors associated with its onset within a cohort of women with previous history of cesarean section. A cross-sectional study with 90 women assessed from 2020 to 2022. Isthmocele was a composite variable diagnosed by transvaginal ultrasound (TVUS), magnetic resonance imaging (MRI) and/or diagnostic hysteroscopy (DxHys) and were asked about clinical symptoms, sociodemographic and obstetrical history and quality of life by the WHO-QOL questionnaire. Univariate and multivariate analysis (odds ratio (OR) plus 95% confidence intervals-CI) were performed to seek factors associated with the presence of isthmocele (5% significance level).The prevalence of isthmocele after combining MRI, TVUS and DxHys was 63.3% (n = 57). Women with isthmocele presented a higher body mass index (BMI) measured during delivery (32.70 ± 6.07 vs. 28.28 ± 9.86kg/m2;p < 0.05) than women without isthmocele. Other sociodemographic variables, obstetrical history and WHO-QOL subdomains did not differ between groups. Within women with isthmocele, the residual myometrial mantle had an average of 4.97 ± 1.57cm. Uterine volume was higher in the isthmocele group (103.95 vs. 81.34 cm3; p = 0.08), but with no statistical difference. Multivariate analysis (logistic regression) has reported that the factors associated with isthmocele were: higher BMI during delivery (aOR = 1.26[1.07-1.49];p < 0.05); longer interpartum interval (aOR = 1.22[1.03-1.46];p = 0.02) and presence of more than two cesarean sections (aOR = 2.16[1.16-4.01];p = 0.02). We concluded that a high prevalence of isthmocele was found. Women with previous cesarean section, with higher BMI during delivery and longer interdelivery interval were risk factors for the presence of isthmocele.

Effect of preprocedure anxiety and oestrogen levels on Postoperative Nausea and Vomiting in patients undergoing diagnostic laparoscopy and hysteroscopy for infertility: A prospective observational pilot study

Effect of preprocedure anxiety and oestrogen levels on Postoperative Nausea and Vomiting in patients undergoing diagnostic laparoscopy and hysteroscopy for infertility: A prospective observational pilot study

Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review.

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

Reproductive Outcomes After Hysteroscopic Adhesiolysis in Patients Experiencing Recurrent Pregnancy Loss and Intrauterine Adhesions

ObjectiveThis study aims to evaluate the reproductive outcomes after hysteroscopic adhesiolysis in patients experiencing recurrent pregnancy loss (RPL) combined with intrauterine adhesions (IUA). DesignSingle-center retrospective cohort study. SettingInternational referral hospital for women with IUA and RPL. PatientsBetween January 2018 and June 2022, a cohort of 64 women diagnosed with RPL and IUA were studied, with a follow-up period of at least one year after hysteroscopic adhesiolysis. InterventionsAll patients had a diagnosis of IUA from the diagnostic hysteroscopy and were treated with hysteroscopic adhesiolysis, utilizing intraoperative ultrasound monitoring as required. Main MeasurementsLive birth rate and menstrual pattern change (subjective assessment) after hysteroscopic adhesiolysis. ResultsIn our cohort, 59.38% (38/64) achieved pregnancy following hysteroscopic adhesiolysis, with 92.11% (35/38) conceiving within two years of the procedure. The miscarriage rate was recorded at 17.19% (11/64), and the live birth rate stood at 42.19% (27/64). Throughout the extended follow-up period, 64.06% (41/64) of the patients reported increased menstrual blood volume and improvements in menstrual patterns posthysteroscopic adhesiolysis. Univariate analysis indicated that being aged ≥35 years (p = .026), having a history of infertility (p = .003), the presence of moderate or severe IUA (p = .023), and experiencing menstrual improvements postsurgery (p = .001) were independent predictors of live birth. Multivariate analysis further identified that women with a history of infertility had a reduced chance of live birth following hysteroscopic adhesiolysis (p = .008), while those who reported menstrual pattern improvements postoperatively had an increased probability of achieving a live birth (p = .031). ConclusionsOur findings indicate that RPL and IUA patients without prior infertility and showing menstrual pattern improvement after hysteroscopic adhesiolysis, are more likely to achieve live births. Standardized hysteroscopic treatment, postoperative antiadhesion care, and early pregnancy planning are key to improving fertility outcomes in these patients.

Dilapan-S versus vaginal misoprostol for cervical preparation before diagnostic hysteroscopy: a prospective randomized controlled trial

Dilapan-S versus vaginal misoprostol for cervical preparation before diagnostic hysteroscopy: a prospective randomized controlled trial

Caesarean scar defect and retained products of conception (RPOC): a step-by-step combined hysteroscopic and laparoscopic treatment.

Uterine scar defect (also called uterine niche or isthmocele) associated to retained products of conception (RPOC) is an uncommon occurrence following caesarean section. Typically, the primary indicator is abnormal vaginal bleeding, and an accurate diagnosis can be established through ultrasound evaluation. Several surgical and endoscopic treatments have been described. To show a step-by-step video of combined hysteroscopic and laparoscopic approach to perform isthmocele repair in a patient with caesarean scar defect and RPOC. We report a case of a 34-year-old patient who was referred to our Digital Hysteroscopic Clinic (DHC) for abnormal vaginal bleeding and persistent pelvic pain, three months after a caesarean section. A single-step diagnostic approach through transvaginal ultrasound and diagnostic hysteroscopy revealed the presence of an isthmic uterine niche within the caesarean scar area, containing a poorly vascularised heterogeneous hyperechoic focal mass measuring 33x11x33 millimetres. Removal of RPOC and surgical complications. All retained placental tissue was removed and the uterine wall defect was corrected. No complications occurred and the patient was discharged two days after the procedure. Patient was asymptomatic at 3 months follow up and ultrasound and hysteroscopy showed a reconstituted uterine wall. An integrated hysteroscopic and laparoscopic approach seems to be an effective conservative method to remove RPOC and perform isthmocele repair with optimal surgical results.

The Correlation of Hysteroscopy and Histopathology in Evaluating Abnormal Uterine Bleeding: Observations From a Tertiary Care Center.

Abnormal uterine bleeding (AUB) is an important clinical entity, and its subtype, heavy menstrual bleeding (HMB), affects 14%-25% of women of reproductive age, potentially impairing their physical, emotional, social, and material quality of life. However, in addition to prior studies that supported the efficacy of hysteroscopy in identifying AUB, this study determined the overall pattern of abnormalities in AUB and correlated the diagnosis through hysteroscopy and histopathology. Additionally, a comparison of ultrasonography was done in this study. This study helps healthcare providers provide timely diagnosis and, thereby, timely interventions in treating different causes of AUB. This hospital-based prospective observational study was conducted at a tertiary care center, including women aged 20-60 admitted with complaints of AUBbetween September 2022 and June 2024. Participants were selected based on their willingness to participate in the study. A statistical analysis was performed using relevant descriptive statistics andplotting the frequency and percentage. Cohen's kappa was applied to ascertain significant associations and patterns within the dataset. Results: The study included 47 women who were admitted to the hospital for diagnostic hysteroscopy. A majority of clinical symptoms presented as menorrhagia (17, 36.2%). The hemoglobin (g/dL) ranged from 5.9 to 14.7. Overall, on hysteroscopy, 37 (78.7%) women had a normal uterus. On hysteroscopy, 36 (76.6%) participants showed a normal cervical canal and cervix. In terms of histopathology, a majority of the study population (21, 44.7%) had proliferative endometrium. In terms of the correlation between hysteroscopy and histopathology, the two methods agreed in 83% of cases and disagreed in 17% of cases. Thisstudy confirms that hysteroscopy is a crucial tool for assessing patients with AUB, particularly those with a thick endometrium, across all age groups. It does not replace other diagnostic methods; instead, it enhances them. Hysteroscopic-guided biopsy along withhistopathology is now widely regarded as the most reliablemethod and new gold standardfor assessing cases of AUB.

Is Hysteroscopic Metroplasty Advisable for U2bC2V1 Malformation?

A complete uterine septum, with a double cervix and vaginal septum, is a complex and rare congenital genital tract anomaly. The diagnosis is difficult and often challenging, requiring complex imaging investigations and diagnostic hysteroscopy. The benefit of hysteroscopic metroplasty for this uterine malformation is still the subject of dispute. However, the potential benefits of obtaining pregnancies and reducing the rate of abortions make this surgical method a desirable one. We present a series of three cases with U2bC2V1 malformation that were diagnosed via magnetic resonance imaging (MRI), in which hysteroscopic removal of the uterine septum and resection of the longitudinal vaginal septum were performed, with the preservation of the two cervixes. All patients became pregnant after the hysteroscopic intervention and reported an improvement in dyspareunia and dysmenorrhea.

Pain experience with outpatient hysteroscopy: A prospective cohort study

BackgroundAbnormal uterine bleeding (AUB) affects women of all ages and is one of the most common reasons for referral to a gynaecological clinic. Operative hysteroscopic procedures allow for a see-and-treat approach to AUB, and these techniques have been shown to be feasible and acceptable in the outpatient setting. ObjectiveTo assess if there is an increase in pain scores for women who are undergoing an operative hysteroscopic procedure with Myosure LITE® (Hologic; mechanical hysteroscopic tissue removal system) compared to outpatient diagnostic hysteroscopy alone. Study designA prospective cohort study was performed. All participants attending the outpatient hysteroscopy clinic at Mercy Hospital for Women completed a pre-and post-procedure questionnaire. This included a visual analogue scale (VAS) for any pre-existing pain, anticipated pain, and actual pain experienced during procedure. Factors influencing overall satisfaction and willingness to attend again were also assessed. Data was entered into RedCap® for analysis. A difference in VAS of 10 mm or more was considered clinically significant. An alpha of p < 0.05 was assigned for statistical significance. ResultsBetween February 2020 and November 2022, 208 women underwent outpatient diagnostic hysteroscopy followed by an operative hysteroscopy with MyoSure®. To allow for standardisation of analgesia, only participants who had a cervical block before their Myosure® procedure were included for analysis (n = 111). There was statistical evidence (t(111) = 2.36, p = 0.02) of a lower mean VAS pain score for operative Myosure (36.5 mm, 95 % CI: 31.1–41.8 mm) compared to outpatient diagnostic hysteroscopy (44.1 mm, 95 % CI: 39.0–49.2 mm). The mean difference in VAS pain score was estimated as 7.7 mm (95 % CI: 1.2–14.1 mm) lower for Myosure compared to hysteroscopy. Given the threshold for clinical significance was considered as 10 mm difference in VAS, the variance in pain scores is under the likely clinically significant range. There was no significant difference in pain scores for diagnostic hysteroscopy with or without paracervical block (mean difference = 1.42; 95 % CI: −6.35 to 9.20). There was no association between pre-existing pain, and actual pain for hysteroscopy, or Myosure (p = 0.997 and p = 0.065 respectively). The anticipated pain score was weakly associated with actual pain during the operative Myosure procedure (p = 0.02), and with outpatient diagnostic hysteroscopy (p = 0.019). ConclusionOutpatient hysteroscopy procedures are generally well tolerated. The pain experience with operative Myosure was less than that reported during the diagnostic hysteroscopy by the same patient although this is unlikely of clinical significance. Importantly, Myosure was not more painful than the initial diagnostic procedure, and most patients were satisfied with the outcome and would choose to have the procedure again in an outpatient setting. This is in keeping with other studies which have shown a high degree of patient tolerance and satisfaction with this approach.

Methoxyflurane analgesia for outpatient hysteroscopy: A double-blind, randomised, controlled trial.

Despite clinical and economic benefits, pain during outpatient hysteroscopy (OPH) remains a barrier to use. There is a lack of evidence to support routine use of one analgesic over another versus no analgesic. To study the efficacy and safety of methoxyflurane analgesia during OPH. A single-centre, randomised, double-blind, placebo-controlled experiment was performed; 90 patients were randomly assigned (1:1). Participants allocated to the treatment group (cases) received 3 mL of methoxyflurane through an inhaler. The control group received a placebo. The primary outcome was a mean difference in pain, via a change in Visual Analog Scale (VAS) score from baseline at diagnostic hysteroscopy. Secondary outcomes were a mean difference in VAS score with any subsequent operative procedures; a mean difference in VAS score at 15 min post-procedure; participant and clinician-reported adverse effects and events; and participant-reported procedure acceptability, adjuvant nitrous oxide (N2O2) use and a composite of 'distress'. During diagnostic hysteroscopy, there was a mean difference of 11.5 mm/100 (95% confidence interval (CI) 0.08-22.95), P = 0.05, with the lower score in the cases, compared with controls. During subsequent operative procedures, there was a mean difference of 15 mm/100 (95% CI 2.71-28.22), P = 0.02, with the lower pain score in the cases, compared with controls. There was no significant difference in pain 15 min post-procedure, participant- and clinician- reported adverse effects and events, procedure acceptability and the 'distress' composite. Methoxyflurane significantly reduced pain during OPH compared with placebo, for diagnostic as well as operative procedures. Furthermore, methoxyflurane was well tolerated, with no adverse events.

Fertility-sparing strategy in a rare case of highly malignant Dicer-1-associated sarcoma of the cervix

IntroductionWe present the rare case of an 18-year-old patient with a Dicer-1 mutation-associated sarcoma of the cervix uteri.CaseThe patient presented with irregular vaginal bleeding in July 2022. The clinical examination showed an exophytic tumor of the cervix, uterus and ovaries were normal in sonogram. The tumor of the cervix was resected, followed by a diagnostic hysteroscopy and abrasion of the uterine cervix and cavity. Hysteroscopy showed normal findings of the cervix and uterus. After diagnosis of a highly malignant Dicer-1 mutation-associated sarcoma of the cervix, cryopreservation of oocytes was realized. Based on the principle of obtaining maximum oncological safety while preserving fertility in this 18-year-old patient, we recommended chemotherapy rather than radiation with its far severe implications on the patient´s reproductive organs. 4 cycles of chemotherapy consisting of doxorubicin and ifosfamide were applied until December 2022. After re-staging in December 2022 via CT scan and MRI, the abdomen and pelvis as well as control hysteroscopy and abrasion were unremarkable. Until now, the patient is tumor free.DiscussionPrimary sarcomas of the cervix are very rare. Recent literature hints towards a distinct DICER-1 sarcoma entity characterized by specific mutational clusters. Limited follow-up data suggested that DICER1-mutant tumors might exhibit a less aggressive clinical course than DICER1-wild-type tumors.ConclusionDecision-making in case of rare histological entities with sparse recommendations in the literature poses a challenge to the treating physician. Treatment strategies should consider oncological safety as well as options of preserving fertility. Gonadotoxic potential of different strategies should be taken into consideration and discussed in detail with the affected patient.

P-742 In-vitro fertilization outcomes after laparoscopic repair of cesarean scar defect

Abstract Study question Does laparoscopic repair of cesarean scar defect improve in-vitro fertilization (IVF) outcomes? Summary answer Laparoscopic (LSC) repair of cesarean scar defect (CSD) should selectively indicated to patients experiencing repetitive pregnancy failure or having an increased depth of niche What is known already Cesarean section (CS) rate has markedly from 7% in 1990 to an estimated 29% of all births by 2030. CSD, also known as isthmocele or uterine niche, has emerged as a cause of secondary infertility, frequently encountered with recurrent implantation failures and cycle cancellations because of the endometrial fluid collection both in endometrium and uterine lower segment of cesarean scar. Study design, size, duration This is a retrospective study encompassing total of 62 patients. With 50 patients undergoing expectant management, 12 undergoing LSC repair of CSD at a single IVF center from 2019 to 2023. Primary outcomes included the clinical pregnancy rate and time to pregnancy, while secondary outcomes were the depth of CSD and residual myometrial thickness. Of the 72 patients, 68 patients underwent frozen embryo transfer. Participants/materials, setting, methods Patients with secondary infertility who had experienced more than two instances of implantation failure or cycle cancellation due to endometrial fluid collection were included. Laparoscopic repair of CSD was performed by a single gynecologic oncologist in accordance with the physician’s preference and patient consent. For patients in expectant management, diagnostic hysteroscopy and endometrial fluid suction were conducted prior to embryo transfer. Main results and the role of chance The age, BMI, gravidity, parity, or the number of previous cesarean section showed no statistical differences between the expectant management and the LSC repair group. The uterine position, either anteflexion was similar across groups. (all p value &amp;gt;0.05). Both the clinical pregnancy rate and live birth rate did not significantly differ between the expectant management group and the LSC repair group (26.0% vs 50.0%, p = 0.149, and 32.0% vs 60.0%, p = 0.149, respectively). The mean time to pregnancy was 7.38 months in the expectant management group and 9.80 months in LSC repair group, showed no significant difference (p = 0.240). Correlation analysis revealed a significantly moderate correlation between the initial depth of CSD and the depth of CSD at embryo transfer with clinical pregnancy (r = -0.424, P = 0.001). Furthermore, our data indicated that the CSD depth at embryo transfer was significantly impacted on clinical pregnancy outcomes from the multivariate regression logistic analysis (OR = 0.522, 95% CI [0.332 – 0.823]). Limitations, reasons for caution This study is retrospectively designed and including small sample size, caution is required in interpreting the findings. Wider implications of the findings This study suggests that the depth of niche influences clinical pregnancy outcomes. Laparoscopic repair may offer a viable treatment option who have experienced multiple failed cycles and increased depth of niche. Future studies with larger population studies may further indicate the LSC repair based on the depth of CSD. Trial registration number not applicable

P-744 A new hysteroscopic-assisted mock embryo transfer (HAMET) to predict success in ART cycles

Abstract Study question Could HAMET increase pregnancy rates in predicted and unexpected difficult transfer patients? Summary answer Data of this study show a strong correlation between HAMET and pregnancy rates. What is known already Mock embryo transfer is regularly performed to adequately plan the correct strategy for positioning embryos inside the uterus of patients predicted to have difficult access to uterine cavity procedure. Study design, size, duration This is a single-center, observational, retrospective study conducted at S.I.S.Me.R. center in Bologna, Italy. 1184 consecutive diagnostic hysteroscopies were performed for patients suffering for primary or secondary infertility before ART. All patients from 18 to 49 years old underwent a mock embryo transfer performed with 10 to 15 μl of methylene blue dye. Diagnostic hysteroscopy was performed immediately after mock embryo transfer to assess if the dye has entered the uterine cavity. Participants/materials, setting, methods Out of the 1184 patients who underwent hysteroscopy, in 617 patients 1118 transfers were executed after IVF-ICSI cycles. Patients were subdivided in: group A where whole cavity including fundus was filled by blue; group B where cavity but not fundus was filled by methylene blue; group C patients with partial captation or with no captation at all of dye. The difficulty of mock embryo-transfer (scale 1 to 3) was also recorded by the physician. Main results and the role of chance the results of 1118 transfers are summarized in the table below. While patients with whole cavity plus fundal captation (group A) had the highest implantantion rate (IR) compared to group B and C, reflecting the same difference in the clinical pregnancy rate (CPR), the live birth rate (LBR) was statistically superior only for group A when compared to group B. Limitations, reasons for caution Main limitation of these findings is the absence of control group. Wider implications of the findings HAMET is able to predict which patients have the higher chances to achieve a pregnancy and, even more important, a term pregnancy. The use of HAMET it is also useful to assess the capability of physicians to enter the uterine cavity when the cervical canal route is not regular. Trial registration number not applicable

P-740 Septoplasty versus expectant management in women with septate uterus and a previous history of a live birth

Abstract Study question Does hysteroscopic septoplasty improve reproductive outcome in patients who were diagnosed to have a septate uterus (SU) after a previous live birth? Summary answer This study suggests that hysteroscopic septoplasty improves the chance of a live birth in patients with both SU and a history of previous live birth. What is known already SU accounts for 50% of uterine anomalies and can be associated with adverse pregnancy outcomes. Many observational studies reported significant improvement in pregnancy outcomes following hysteroscopic septoplasty. However, some investigators have reported good reproductive outcome among women with SU without surgical interventions. A recent randomized controlled trial, albeit with a small sample size, reported no difference in reproductive outcomes between patients who underwent hysteroscopic septoplasty and those who had no surgery (Rikken 2021). Therefore, more studies are needed to be able to counsel patients with SU presenting with reproductive failure, especially those with a history of a previous live birth. Study design, size, duration This retrospective study included 114 patients who had a previous live birth and subsequently complained of reproductive failure. A SU was diagnosed during their work up between 2005-2022. Patients presented with secondary infertility (98.3%) or with recurrent pregnancy loss (RPL) [1.7%]. Forty-two patients presented with both secondary infertility and RPL (36.8%). Participants/materials, setting, methods Diagnosis of SU was suspected on transvaginal 3D ultrasound scan and was confirmed on a diagnostic hysteroscopy at an infertility clinic affiliated with an academic hospital. Patients were offered the option of hysteroscopic septoplasty or expectant management. Infertility treatment options depended on the underlying etiology and included spontaneous conception, oral fertility medications, intrauterine insemination, and in-vitro fertilization/embryo transfer. Eighty-two patients underwent hysteroscopic septoplasty (Group 1), while 32 patients declined surgery (Group 2). Main results and the role of chance There were no significant differences in mean age (years), BMI (Kg/m2), infertility duration, baseline FSH levels (mIU/mL), number of miscarriages, and gestational age at delivery before treatment between the two groups. There were no significant differences in incidence of ≤ 3 or ≥ 3 pregnancies, nor incidence of one live birth or &amp;gt; 1 live birth between the two groups. There were no significant differences in the underlying etiology, except for a significantly higher incidence of endometriosis (P = 0.004) and diminished ovarian reserve (P = 0.04) in Group 1 compared to Group 2. There were no significant differences in the incidence of partial septate uterus (PSU) [angle of indentation &amp;lt;90 degrees] and complete septate uterus between the two groups. However, there was significantly lower incidence of PSU with angle of indentation &amp;gt; 90 degrees (P = 0.028) and higher mean septum length in mm (18.9±1.0 vs 13.8±1.1, P = 0.024) on hysteroscopy in Group 1 compared to Group 2. After treatment, there were significantly higher pregnancy (68.3% vs 37.5%, p = 0.003) and live birth (61.7% vs 25%, P = 0.000) rates, but no significant difference in miscarriages (4.9% vs 6.3%), preterm birth (14% vs 25%) rates, or method of pregnancy in Group 1 compared to Group 2. Limitations, reasons for caution Our study has limitations being retrospective in nature with a small sample size. Therefore, more studies are required to support our findings. However, our pilot study explored management options in a particular group of patients with SU who initially proved their fertility and subsequently presented with reproductive failure. Wider implications of the findings Our data support the notion that patients with SU can have a normal reproductive outcome, although those who undergo septoplasty are expected to have a better chance of conception and live birth. During counselling of patients with SU, both surgical and expectant management can be offered. Trial registration number not applicable