Normal Uterine Cavity Research Articles

Optimal follicular size for ovulatory trigger in natural and clomiphene citrate intrauterine insemination cycles

Intrauterine insemination (IUI) during a natural cycle (NC) or following ovulation induction with clomiphene citrate (CC) forms the mainstay of fertility treatment in many young patients. IUIs in such patients are frequently performed after administration of a human chorionic gonadotropin (hCG) ovulatory trigger. The primary objective of this study is to identify the optimal lead follicular size for an ovulatory trigger in either NC or CC IUI cycles. Retrospective cohort study. Patients <40 years of age, with patent fallopian tubes, a normal uterine cavity, and a male partner with >15 million sperm/mL, undergoing an IUI in either a NC or CC ovulation induction cycle between 2004 and 2013 were analyzed for inclusion. All patients with a spontaneous LH surge or undergoing successive IUIs in the same treatment cycle were excluded. The hCG ovulatory trigger was administered either subcutaneously or intramuscularly, after visualization of a >17 mm follicle in the NC group or >19 mm follicle in the CC group, and an endometrial thickness of >7 mm in both groups. IUIs were performed 24-30 hours following the ovulatory trigger. Clinical pregnancy rates were plotted for the NC and CC groups against lead follicular size, in increments of 1 mm beginning at 17 mm. Odds ratios (OR) for clinical pregnancy at different lead follicular sizes were calculated by using 17 mm and 19 mm as reference values for the NC and CC groups, respectively. 3272 IUI cycles met inclusion criteria: 1201 NC and 2071 CC. The median age in the NC and CC groups was 36.4 (31.4-41.4) years and 34.3 (29.8-38.8) years, respectively. In the NC group, the clinical pregnancy rate (14%) was highest when the ovulatory trigger was administered at a lead follicular size of 19 mm compared to the reference group of 17 mm (8%). However, these odds were not statistically significant (OR 1.80, 95% CI 0.73-4.41). The aforementioned odds remained unchanged even after adjusting for age. In contrast, the clinical pregnancy rate in the CC group was highest when the lead follicular size was 22 mm at the time of the ovulatory trigger (16%). Compared to the reference group of 19 mm, the odds for clinical pregnancy with a lead follicle of 22 mm was 2.14 times higher (OR 2.14, 95% CI 1.20-3.83; P=0.01). The higher odds for clinical pregnancy persisted even after stratifying for age: 25-35 years (OR 2.55, 95% CI 1.25-5.20) and 35-40 years (OR 1.90, 95% CI 1.01-3.58). Our results suggest that administration of a hCG ovulatory trigger at a lead follicular size of 22 mm is associated with higher odds of clinical pregnancy in patients undergoing IUI following ovulation induction with CC. Although triggering at a lead follicular size of 19 mm in the NC group is also associated with an increased odds of clinical pregnancy, these odds remain non-significant when compared to the reference group of 17 mm.

Impact of luteal phase support with vaginal progesterone on the clinical pregnancy rate in intrauterine insemination cycles stimulated with gonadotropins: a randomized multicenter study

To evaluate the effect of luteal phase support (LPS) in intrauterine insemination (IUI) cycles stimulated with gonadotropins. Randomized multicenter trial. Academic tertiary care centers and affiliated secondary care centers. Three hundred and ninety-three normo-ovulatory patients, <43years, with body mass index ≤30kg/m2, in their first IUI cycle, with at least one patent tube, a normal uterine cavity, and a male partner with total motile sperm count ≥5 million after capacitation. Gonadotropin stimulation, IUI, randomization to LPS using vaginal progesterone gel (n = 202) or no LPS (n = 191). Clinical pregnancy rate, live-birth rate, miscarriage rate, and duration of the luteal phase. The primary outcome, the clinical pregnancy rate, was not statistically different between the treatment group (16.8%) and the control group (11%) (relative risk [RR] 1.54; 95% confidence interval [CI], 0.89-2.67). Similarly, the secondary outcome, the live-birth rate, was 14.9% in the treatment group and 9.4% in the control group (RR 1.60; 95% CI, 0.89-2.87). The mean duration of the luteal phase was about 2days longer in the treatment group (16.6 ± 2.2days) compared with the control group (14.6 ± 2.5days) (mean difference 2.07; 95% CI, 1.58-2.56). Although a trend toward a higher clinical pregnancy rate as well as live-birth rate was observed in the treatment group, the difference with the control group was not statistically significant. NCT01826747.

Evaluation of uterine cavity by hysteroscopic examination in infertile women in BSMMU

Background: Hysteroscopy is the gold standard procedure for uterine cavity exploration. However, hysteroscopy is only recommended by the WHO when clinical or complementary exams (ultrasound, HSG) suggest intrauterine abnormality or after in vitro fertilization failure. Nevertheless, many specialists feel that hysteroscopy is a more accurate tool.Objec­tive: The aim of this prospective study is to find out the evaluation of uterine cavity by hysteroscopic examination as a primary workup of infertility. To asses the uterine pathology which is the causal factor for infertility.Method: This is a cross sectional study in which total 100 infertile patients were enrolled from infertility OPD in BSMMU with maintain­ing inclusion and exclusion criteria Hysteroscopy was performed with a standard sequence. The endocervical canal, uterine cavity, endometrium, and tubal ostia were inspected and findings were recorded. Results: Hysteroscopy was performed in 100 infertile women,among them 44% were presented with primary infertility and 56% presented with secondary infertility. The most common indication for diagnostic hysteroscopy was as a part of an infertility workup 80% cases. Other indication included abnormal hysterosalphingography, recurrent pregnancy loss and unexplained infertility. Hysteroscopy revealed a normal uterine cavity in 51 ( 51 % ) women (Table 2).among them majority of patients were primary infertility.and age less than 30 years. Hysteroscopic abnormalities are significantly high in secondary than primary infertility.Conclusion: In this study abnormal hysteroscopic findings were found in 49% who underwent diagnostic hysteroscopy. Our data are an additional argument to suggest that diagnostic hysteroscopy as part of investiga­tion in infertile woman to evaluate uterine pathology. Routine diagnostic hysteroscopy should be part of an infertility workup in both primary and secondary infertility.At the same setting therapeutic approach also be possible which is beneficial for the patients.

A Long Term Follow up of Results of Women undergoing an Office based Thermablate Endometrial Ablations for the Treatment of Menorrhagia

Background:Heavy menstrual bleeding (HMB) or menorrhagia accounts for 20% of outpatient referrals to secondary gynaecological services. The Thermablate Endometrial Ablations system (EAS) is an example of a second generation of EAS used for treating menorrhagia of benign origin; reducing the necessity for a hysterectomy. The study aimed to explore long term results and success of this system’s use in an outpatient setting. Methods:This prospective observational study examined the long term follow up of 175 women attending an outpatient setting, having a Thermablate EA between July 2008 and July 2013. Women included had menorrhagia unresponsive to medical or hormonal therapy; and demonstrated a normal uterine cavity on hysteroscopy. They all received oral analgesia preceding ablation and welfare was ensured post procedure. Final outcomes were gathered using NOTIS; determining intervention rates following Thermablate EAS and satisfaction and improvement of quality of life through minimisation of bleeding and better symptom control. Results:Of the 173 women, 93 women (53.7%) had lighter menstrual periods and 45 women (26%) became amenorrhoeic. 138 women (79.7%) had no interventions following Thermablate EAS. Our complication rate was 1.2%. 11 women went on to have hysterectomy for persistent uterine bleeding. Key message:Thermablate EAS is an extremely well tolerated device ideal for use in the outpatient office setting. The long term results demonstrate high satisfaction rates and better symptom control acceptable to most women. Low intervention rate demonstrated in the form of hysterectomy has important cost implications for the NHS.

Should hysteroscopy be combined with laparoscopy in endometriosis associated infertility?

ObjectivesThe aim of this study was to evaluate the uterine cavity in cases of endometriosis associated infertility using office hysteroscopy. Study designA retrospective observational analytical study. Patients and methodsThe study conducted on 50 women with endometriosis diagnosed by laparoscopy seeking fertility treatment between December 2013 and October 2015. The study was approved from Ethical committee board of the faculty of Medicine Alexandria University. After explanation of the study objectives and procedures to all eligible women, informed written consent was signed. Thorough history taking, clinical examination and vaginal ultrasound examination was conducted to all participants. Office Hysteroscopy was done in the early proliferative phase using normal saline as a distention medium. All data were pulled from the reports at Elshatby Maternity University Hospital. ResultsThe age of the study group was ranging from 20 to 34 years with the mean of 29 years±3 years. 42 cases were primary infertility counting for 84% of patients and 8 cases were secondary infertility counting for 16% of patients. This reflects the strong impact of endometriosis on fertility. Normal uterine cavity was diagnosed in 35 cases representing 70% of the studied patients group. 10 cases had endometrial polyps representing 20% of the studied patients group. 5 cases had a uterine septum representing 10% of the studied patients group. 2 cases had a hypo plastic uterus in addition to uterine septum representing 4% of the studied patients group. Normal uterine cavity were diagnosed using hysteroscopy in 63.0% (18/23) in women having ovarian endometrioma while this normality was 78.3% (17/27) in women without endometrioma however, The prevalence of endometrial polyp was 25.9% in cases with endometrioma and 13% in cases without endometrioma. Cases with a uterine septum were 7.4% (2/23) of cases having ovarian endometrioma and 13.0% (3/27) of cases without it. Two cases with endometrioma out of 23 cases were diagnosed to have hypoplastic uterus. No uterine abnormalities were found in stage 1 endometriosis in contrast to the presence of 53.2% of patients with a uterine abnormality in stage 2. Also stage 3 patients were all having a normal uterine cavity while only 72.4% of patients with stage 4. ConclusionFrom the results of this study we can conclude that there is a High prevalence of endometrial polyps in cases of endometriosis. Also there is a High prevalence of uterine anomalies in cases of endometriosis. Still, we neither cannot recommend hysteroscopy as a routine in any endometriosis patient undergoing laparoscopy.

Preterm Birth and IVF-ET in Singleton Pregnancy After Hysteroscopic Correction of Uterine Septum [27H

INTRODUCTION: The purpose of this study is to compare preterm birth rate in a cohort of women with primary infertility, and hysteroscopically corrected incomplete uterine septum or arcuate uterine anomaly, who subsequently conceived singleton gestation via spontaneous conception (SC), or intrauterine insemination after controlled ovarian stimulation (IUI+COS) or IVF-ET. METHODS: This retrospective study included women with primary infertility and incomplete uterine septum or arcuate uterine anomaly. All patients underwent successful hysteroscopic septoplasty that resulted in a normal uterine cavity postoperatively between 1992–2011. Subsequently all patients conceived singleton gestation by SC, IUI+COS, or IVF-ET. The study included 106 patients, 45 conceived spontaneously, 11 with IUI+COS, and 50 with IVF-ET. The primary outcome was the preterm birth rate. Secondary outcomes were gestational age at delivery and neonatal birth weight. RESULTS: There was a significant difference in age, but no significant differences in duration of infertility, BMI, day 3 FSH levels or underlying etiology among the three groups. There was no statistical difference in preterm birth rates (17.8% vs 27.3% vs 16%), mean gestational age at delivery in weeks (38.6±2.5 vs 37.6±3.6 vs 36.6±7.0), and birth weight in Kg (3.3±0.6 vs 3.1±0.8 vs 3.2±0.7) between SC, IUI+COS, and IVF-ET groups respectively. CONCLUSION: Our data suggest that in patients with incomplete uterine septum or arcuate uterine anomaly, who underwent successful hysteroscopic correction, IVF-ET treatment per se is not associated with increased risk of preterm birth and/or low birth weight.

Intrauterine Adhesions Following Miscarriage: Look and Learn.

To examine the incidence of intrauterine adhesions (IUA) following the management of miscarriage in women with previously documented normal uterine cavities. We conducted a retrospective cohort study from two fertility clinics with standard practice protocols for evaluating the uterine cavity prior to infertility treatment and following clinical pregnancy loss. A database query and manual chart review identified 144 women with normal uterine cavities who experienced a miscarriage between January 2010 and November 2012 and returned to the clinic for follow-up hysteroscopy. Following documentation of a non-viable clinical pregnancy using transvaginal ultrasound, patients chose expectant, medical, or surgical management according to standardized clinical protocols. The primary outcome was the detection of IUA. Secondary outcomes included the presence of retained products of conception and various risk factors associated with the development of IUA. The incidence of IUA following early pregnancy loss was 6.3%. There were no significant differences in patient characteristics between those with and without IUA. There was a significant association between IUA and increasing uterine size, particularly in the presence of multiple gestation (P= 0.039). Mechanical suction dilatation and curettage (D&C) was a risk factor for IUA, but manual vacuum aspiration was not a risk factor (P= 0.003). Retained products of conception were found in 13.9% of study participants, and the incidence did not differ among management options. This appears to be the first documentation of IUA that were entirely attributable to the index miscarriage or its management. There appears to be an increased risk of IUA following D&C with larger uteri and multiple pregnancies and following mechanical suction D&C.

Endometrial LGR7 expression and implantation failure

Implantation failure is considered as a major cause of infertility in women with recurrent pregnancy loss (RPL) and in otherwise healthy women with unexplained infertility. Preliminary data in primates suggested that relaxin (RLX) is involved in endometrial preparation for implantation. In a prospective observational study, the endometrial RLX receptor (LGR7) expression was assessed in three groups of patients with regular ovulatory cycle and normal uterine cavity: 23 with RPL (Group A), 23 with unexplained infertility undergone at least three cycles of failed in vitro fertilization (IVF) reporting good oocyte and embryo quality (Group B), 23 with proven fertility (Group C). Assessment of LGR7 expression was performed with both polymerase chain reaction (PCR) analysis and immunohistochemistry on endometrial samples obtained with hysteroscopic biopsy performed in the secretory phase of the menstrual cycle. Endometrial LGR7 was less expressed in group A and B versus C, both by PCR analysis (p = 0.024) and immunohistochemistry. The decreased expression of the endometrial RLX receptor in women with implantation failures, both in vitro fertilization failure and recurrent pregnancy loss, suggests that RLX may play a crucial role in the structural and functional changes of the endometrium during the window of implantation.

Uterocutaneous Fistula –A Rare Clinical Entity

Uterocutaneous fistula is a rare complication that may follow caesarean section. Herein is described a rare case of uterocutaneous fistula. The 35-year-old P3 L3 female patient presented to general surgery OPD with complaints of bleeding from sinus near the caesarean section scar site for last 2 years. She underwent three caesarean sections in the past. Laparotomy was performed. Conservative surgical treatment was successful. At 6-month follow-up, hysteroscopy revealed a normal uterine cavity. We conclude that conservative surgical treatment can be an efficient procedure.

Letrozole, berberine, or a combination for infertility in Chinese women with polycystic ovary syndrome: a multicentre, randomised, double-blind, placebo-controlled trial

BackgroundLetrozole is superior to clomiphene in infertile women with polycystic ovary syndrome and leads to higher ovulation and live birth rates. Berberine, a major active component of Chinese herbal medicine Rhizoma coptidis and found in Cortex Phellodendri and Cortex Berberidis in the rest of the world, has similar but even more profound metabolic effects than metformin. Our hypothesis was that a combination of letrozole and berberine would result in a higher live birth rate than letrozole or berberine alone in infertile women with polycystic ovary syndrome. MethodsIn this multicentre, randomised, double-blind, placebo-controlled trial in 19 participating centres in mainland China, we compared the effect of three interventions for up to six menstrual cycles: letrozole plus berberine placebo (letrozole group), berberine plus letrozole placebo (berberine group), or the combination of letrozole and berberine (combination group). The randomisation (1:1:1) was done through a web-based computer program operated by an independent data center in the China Academy of Chinese Medical Sciences. Participants, investigators, doctors, laboratory technicians, and data analysers were masked to the assignments. Eligible women (age 20–40 years) had polycystic ovary syndrome, as defined by the Rotterdam criteria, had at least one open Fallopian tube and normal uterine cavity, and had at least 1 year of infertility. Berberine or berberine placebo were administrated orally at a daily dose of 1·5 g for 6 months. Patients received an initial dose of 2·5 mg of letrozole or placebo on days 3–7 of the first three treatment cycles. This dose was increased to 5 mg letrozole or placebo on days 3–7 of the last three treatment cycles if not pregnant. Couples were instructed to have regular intercourse two to three times a week until becoming pregnant. The primary outcome was live birth rate after intervention for up to six menstrual cycles. We used either a χ2 test or Fisher's exact test a two-sided significance level of 0·05 to test differences between groups. Data were analysed according to the intention-to-treat principle. This study was approved by an Ethics Committee (2009LL-001) at First Affiliated Hospital in Heilongjiang University of Chinese Medicine. This trial is registered at Chinese Clinical Trials Registration, identifier ChiCTR-TRC-09000376, and at ClinicalTrials.gov, number NCT01116167. All participants provided written informed consent. FindingsWe enrolled 644 participants. The live birth rates were comparable between the letrozole group (78 [36%] of 215 births) and the combination group (74 [34%] of 215 birth) after treatment (odds ratio [OR] 0·92, 95% CI 0·62–1·37; p=0·687), whereas live birth rates in the berberine group (44 [22%] of 214 births) were lower than in the letrozole group (OR 2·02, 95% CI 1·32–3·10; p=0·001) and the combination group (OR 1·86, 95% CI 1·21–2·86; p=0·004). Conception, pregnancy, and ovulation rates were similar in the letrozole (46%, 39%, and 59%, respectively) and combination groups (49%, 38%, and 61%, respectively), and these were higher than in the berberine group. There was one twin birth in the letrozole group and three twin births in the combination group, but none in the berberine group (29%, 22%, and 6%, respecitively). Berberine was associated with constipation and nausea whereas letrozole was associated with fatigue and hot flashes. InterpretationFor ovulation and live births, the combination of letrozole and berberine did not improve outcomes compared with letrozole alone, but letrozole and the combination of letrozole and berberine improved fertility in women with polycystic ovary syndrome compared with berberine alone. Some limitations include the early study termination because of the expiration of the study drug berberine or placebo, not all participants had pelvic sonograms to assess for polycystic ovaries, and some participants had regular cycles. The major strength of this study is that it was a large multicentre, double-blind trial with close monitoring of adverse events and serious adverse events and tracking of live birth in line with our recent Harbin consensus. FundingNational Public Welfare Projects for Chinese Medicine (200807021) of China, the National Key Discipline of Chinese Medicine in Gynecology during the year of 2009–14, the Heilongjiang Province Foundation for Outstanding Youths (JC200804), the Intervention for Polycystic Ovary Syndrome Based on Traditional Chinese Medicine Theory—‘TianGui Shi Xu’ (2011TD006), and the National Clinical Trial Base in Chinese Medicine during the year of 2009–14 in First Affiliated Hospital, Heilongjiang University of Chinese Medicine.

An Exceptional Case of Complete Septate Uterus With Unilateral Cervical Aplasia (Class U2bC3V0/ESHRE/ESGE Classification) and Isolated Mullerian Remnants: Combined Hysteroscopic and Laparoscopic Treatment

Study ObjectiveTo report the combined hysteroscopic and laparoscopic treatment of a complete septate uterus with unilateral cervical aplasia (class U2bC3V0/ESHRE/ESGE classification) and isolated mullerian remnants. DesignStep-by-step presentation of the surgical treatment (Canadian Task Force classification 4). SettingComplete septate uterus with unilateral cervical aplasia (formally Robert's uterus) is characterized by the presence of a uterine septum completely dividing the endometrial cavity into an obstructed hemicavity and a contralateral nonobstructing hemicavity connected normally to the existing cervix. It has always been described as isolated without any associated anomaly. PatientA 30-year-old woman was referred to our department for dysmenorrhea and primary infertility. Hysterosalpingography showed the presence of a right (RT) hemiuterus with a patent fallopian tube; further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging showed an externally normal-appearing uterus, a right normal hemicavity connected normally with the existed cervix and, a left hemicavity fully divided from the right one by a complete septum and not connected with the cervix. Interestingly, a peculiar complex mass with cystic areas, attached posterolaterally from the left side to the uterine wall at the level of the isthmus and the upper cervix, was also diagnosed. InterventionsThe study protocol was approved by our local institutional review board. During outpatient hysteroscopy, a right uterine hemicavity with a single ostium was identified without any communication with the left hemicavity. The patient was then scheduled for combined laparoscopic and hysteroscopic treatment. During laparoscopy, a normal uterine body with multiple myomas and a pseudocystic lesion attached posteriorly and left laterally to the uterus at the level of the isthmus and the upper cervix were shown; no communication between the cystic part of that lesion and the isthmus or the cervicovaginal canal was observed. During hysteroscopy, a longitudinal incision of the septum with a 5F bipolar electrode was performed; the left hemicavity was opened, and the corresponding tubal ostium was identified. The pseudocystic lesion was then excised after opening and sent for pathological analysis; the defect was closed with interrupted intracorporeal knots. Measurements and Main ResultsA single normal endometrial cavity with both tubal ostia was obtained, thus restoring obstruction by unification of the uterine cavity. A histologic report of the removed pseudocystic lesion was compatible with the diagnosis of mullerian remnants. A follow-up hysteroscopy 3 months after showed a normal uterine cavity without postsurgical adhesions. ConclusionThe use of 3-dimensional ultrasound and magnetic resonance imaging in combination with the new ESHRE/ESGE classification system gives the opportunity to obtain a precise representation of the female genital anatomy even in the presence of complex anomalies. Although a septate uterus with unilateral cervical aplasia has been already described, the presence of mullerian remnants is a rare entity associated with cyclic pelvic pain, thus needing adequate recognition and treatment. The combined hysteroscopic and laparoscopic approach offers a unique opportunity for the treatment of complex anomalies.

Efficacy of natural cycle endometrial preparation for frozen-thawed embryo transfer in patients with endometriosis

To assess the efficiency of natural cycle(NC) endometrial preparation for frozen-thawed embryo transfer (FET) in women with endometriosis(EMS). Retrospective study This was a retrospective study of the use of the natural cycle for endometrial preparation following FET cycles in patients with endometriosis from March, 2011 to August, 2013. The study groups included 97 patients with stage I-II endometriosis who underwent a total of 120 FET cycles(group A, included cases of mild and minimal endometriosis) and 179 patients with stage III-IV endometriosis who underwent a total of 233 FET cycles(group B, included cases of moderate and severe endometriosis). The control group included 258 patients with tubal factor infertility who underwent a total of 300 FET cycles(group C). In stage III-IV endometriosis , 40 patients (47 FET cycles,groupB1) had endometrial cyst recurrence after laparoscopic or laparotomy treatment. All patients enrolled in the study met the following inclusion criteria: (i) normal uterine cavity as assessed by ultrasonography, hysterosalpingography or hysteroscopy; (ii) high-quality frozen embryos were transplanted. (iii)normal male semen. The exclusion criteria comprised: (i) presence of hydrosalpinges; (ii) presence of adenomyosis and (iii) past history of myomectomy;(iv) polycystic ovary syndrome(PCOS); (v)repeated failed intrauterine insemination (IUI ). For group A , B and C ,we used the natural cycle for endometrium preparation. The patients’ characteristics, including age, duration of infertility, body mass index, number of embryos transferred, average endometrial thickness of ET (mm), basal FSH, serum E2 and P of transplantation day, No. of previous failed embryo transfer cycle, the rates of basal FSH>10 were recorded. Secondary measures included clinical pregnancy rate, live birth rate, ongoing pregnancy rate, implantation rate, and pregnancy complication rate. There were comparable clinical pregnancy rate (43.33% stage I-II, 50.21% stageIII-IV and 45.33% tubal factor )and live birth rate(36.67% stage I-II, 41.63% stageIII-IV and 40.00% tubal factor ) among the three groups, not depending on severity of endometriosis . No differences were found in other pregnancy parameters , in terms of ongoing pregnancy rate(36.67% stage I-II, 41.63% stageIII-IV and 40.00% tubal factor ) , miscarriage rate(14.89% stage I-II, 16.24% stageIII-IV and 10.29% tubal factor ), pregnancy complication rate(7.69% stage I-II, 10.26% stageIII-IV and 12.50% tubal factor ). No congenital birth defects were found in the endometriosis groups. In addition, when high-quality embryos are transferred, the pregnancy results are not affected by endometriomas. Natural cycle endometrial preparation for FET obtains similar pregnancy outcomes in patients with endometriosis compared with tubal infertility, and don’t increase the risk of birth defects and other complications.

Pregnancy Outcome after Office Microhysteroscopy in Women with Unexplained Infertility.

Hysteroscopy offers diagnostic accuracy and the ability to treat uterine pathology. The current study aimed to review the findings and feasibility of the proposed office-based diagnostic and operative microhysteroscopy in previously diagnosed wom- en with unexplained infertility and to evaluate the post-microhysteroscopic pregnancy outcome in a-year follow-up period. This prospective controlled study was conducted between 2006 and 2013. Two hundreds women with unexplained infertility were randomized into two groups: A. study group including 100 women recruited for office micohysteroscopic session and B. control group including 100 without the proposed microhysteroscopic intervention. A malleable fiberoptic 2-mm, 0 and 30 degrees angled hysteroscopy along with an operative channel for grasping forceps, scissors, or coaxial bipolar electrode were used for both diagnostic and operative indications. The findings, complications, and patient tolerance were recorded. A-year follow-up of pregnancy outcome for both groups was also performed. Seventy cases (70%) of patients had a normal uterine cavity. Twenty wom- en (20%) had endometrial polyps. Other pathology included submucous myomas in 3 cases (3%), intrauterine adhesions in 3 cases (3%), polypoid endometrium in 3 cases (3%), and bicornuate uterus in one case (1%). The pathological findings were treated in all patients without complication. Also a-year follow-up of the to- tal developing cumulative pregnancy rate (CPR) was evaluated in groups A and B (control). Group A revealed the total CPR of 28.5%, among which 25% in women without pathology, 40% in women with endometrial polyps, 23% in women with adhesions, 33% in women with polypoid endometrium, and 21% in those with bi- cornuate uterus. However, A-year follow-up of spontaneous pregnancy outcome in group B showed a total CPR of 15%. Women tolerance, safety, and feasibility of simultaneous operative correc- tion make the proposed office microhysteroscopy an ideal and routine procedure in order to diagnose and to treat missed intrauterine abnormalities, especially in cases with un- explained infertility, with additional improvement of the pregnancy outcome after the procedure.

A retrospective analysis of ectopic pregnancy in a tertiary care centre in South Kerala

Introduction : Ectopic pregnancy means the presence of pregnancy outside the normal uterine cavity. Ectopic pregnancy commonly occurs in the fallopian tube (95 %). Diagnosis can be made by USG, serum hCG, although the ‘gold standard’ is laparoscopy. Management of the cases depends on the clinical presentation, site of the ectopic and need for future reproductive function and can be medical as well as surgical. Objectives : To determine the incidence of ectopic pregnancy, to assess the percentage of ectopic pregnancy diagnosed with each modality, to identify the factors associated with ectopic pregnancy and to calculate the type of management employed whether medical or surgical. Material and methods : This is a retrospective study where all the cases of ectopic pregnancies 1 st January 2008 to 31 st December 2013 were included. The data on each patient was obtained and was duly entered in M S Excel and descriptive statistical measures were used for analysis Results : The incidence of ectopic pregnancy in the present study was 0.7%. 33.3% patients were primigravida. 5.5% had history of recurrent abortions, 11% of the patients took treatment for infertility, 27.7% had history of previous LSCS, D&C was done in 13% patients and 31.5% had undergone sterilization. In 83.3% ectopic gestation was diagnosed by ultrasound whereas rest 16.7% was diagnosed by serial serum hCG estimation. 22.2% underwent medical management rest 89% patients underwent surgical management. Failure of medical therapy and subsequent surgical management was seen in 50% patients. Conclusions : Ectopic pregnancy causes significant morbidity to the mother and hence requires a high index of suspicion so that diagnosis can be made early and also to prevent complications and preserve the future reproductive function of the patient.

Embarazo gemelar con ovodonación en un caso de síndrome de Turner

Objetivo: Presentar un caso de síndrome de Turner mosaico que logro embarazar con donación de ovocitos y transferencia embrionaria. Lugar: Centro de Reproducción Asistida de fa Clínica Ricardo Palma. Material y Métodos: Paciente de 32 años con síndrome de Turner, 45,0/47,XXX/46,XX, con infertilidad primaria. La preparación del endometrio para la implantación fue inducida con valerianato de estradiol con dosis ascendentes de 2 a 8 mg/día, hasta obtener el grosor endometrial adecuado y calculando el día de la aspiración de los ovocitos. Para el soporte de fa fase lútea se utilizó progesterona micronizada a dosis de 1200 mg/día vía vaginal. La hiper estimulación ovárica controlada en la donante se efectúo usando análogo de GnRH y FSHr, se aspiró 9 ovocitos, utilizándose 5 y, en las siguientes 48 horas, clivaron y fueron transferidos 3 embriones. En el momento cursa gestación gemelar del ll trimestre. Conclusiones: La fertilización in vitro con ovodonación es una alternativa para la infertilidad de las pacientes portadoras del síndrome de Turner. La transferencia embrionaria puede ser realizada en pacientes con cavidad uterina normal.

Hysterosalpingography versus hysterscopy in intrauterine pathology research of infertile patients

Background: The objective of the present paper is to confirm the validity and reliability of hysterosalpingography (HSG) in intrauterine pathology research of infertile female patients by comparing the hysteroscopy (HC) findings to a “gold standard’’ test. Aim: To analyze HSG and HC findings in infertility patients. Materials and Methods: The research was conducted as a prospective study at the Gynecological and Obstetrics Clinic “Narodni front’’ in Belgrade. Results: HSG indicated pathological findings in 72.5% of patients whereas HC revealed abnormalities of uterine cavity in 77.5%. In 12.5% of patients, HSG demonstrated a normal uterine cavity, and HC confirmed pathological findings, while in 7.5% of patients with filling defects and irregular shapes on HSG images, HC reported normal findings. In 22.5% of patients normal finding as well as endometrial polyps were reported; congenital malformations (anomalies)were found in 32.5%, submucosal myomas in 12.5% and Asherman’s syndrome in 10%. Conclusion: HC finding was crucial in final diagnosing.

Laparoscopic hysterotomy for a failed termination of pregnancy: a first case report with demonstration of a new surgical technique.

To show a new technique of hysterotomy via laparoscopy for a failed termination of pregnancy as an alternative for a hysterotomy via laparotomy. Step-by-step explanation of the technique using parts of the original video of the procedure (Canadian Task Force classification III). A 39-year-old woman, para 1 gravida 2, was diagnosed with a trisomy 21 pregnancy at 18 weeks' gestation. After 7 days of failed medical and mechanical induction, including misoprostol per vaginam, intravenous sulprostone , intravenous oxytocin, a transcervical Foley catheter, and a transcervical Bakri balloon (Cooke Medical, Bloomington, IN), the decision was made to perform a laparoscopic hysterotomy. A laparoscopic hysterotomy was performed with extraction of the fetus and placenta in an endobag. The uterus was sutured using a double layer of 2 continuous Vicryl 1 sutures (Ethicon, Cincinnati, OH). The umbilical incision was enlarged to 2.5 cm to extract the endobags. The procedure was performed using only standard reusable laparoscopic equipment. The patient's postoperative recovery was uneventful. On the postoperative ultrasound, we suspected that a small piece of placental tissue had been left in the uterine cavity. A hysteroscopy confirmed this and showed a normal uterine cavity. The small placental fragment regressed spontaneously on the follow-up ultrasounds. A 2-year follow-up of the patient has shown no minor or major complications. The patient has used contraception since the procedure because she has no further desire for childbearing. This new technique can help surgeons avoid a laparotomy when a hysterotomy for a failed midtrimester termination of pregnancy is required. The risk of uterine rupture in a next pregnancy needs to be taken into account. This frugally innovative technique may potentially be performed in a low-resource setting because only standard reusable laparoscopic equipment was used.

Clinical relevance of diagnostic hysteroscopy with concurrent endometrial biopsy in the accurate assessment of intrauterine alterations.

The aim of this retrospective observational study was to evaluate the reliability of diagnostic hysteroscopy, routinely performed along with endometrial biopsy, by analyzing and comparing both hysteroscopic and histopathological outcomes in asymptomatic infertile patients, previously to their IVF cycle. The study included 84 consecutive infertile patients who underwent diagnostic hysteroscopy followed by endometrial biopsy. Four-micrometer sections were stained with hematoxylin and eosin and examined microscopically. The data evaluated the frequency and characteristics of endometrial abnormalities found in the biopsies of patients with normal hysteroscopy outcome. Descriptive data are presented as percentages, and the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of hysteroscopy for diagnosis of endometrial alterations were calculated on the basis of pathologic reports. The hysteroscopy evaluation showed 50.0 % of patients with a normal uterine cavity, 40.5 % with endometrial polyps, 6.0 % with endometrial hyperemia, and 3.5 % with other endometrial abnormalities. Among the 42 patients with a normal uterine cavity at hysteroscopic examination, 60.0 % also had a normal biopsy outcome, but in other 40.0 % of patients at least one histopathological abnormal aspect was diagnosed at biopsy. The sensitivity (67.3 %), specificity (80.6 %), PPV (85.4 %) and NPV (59.5 %) of diagnostic hysteroscopy were calculated on the basis of histopathological findings. Our results show that diagnostic hysteroscopy demonstrated intrauterine alterations in half of infertile patients; histopathological endometrial alterations suggest high rate of false-negative outcomes. Therefore, diagnostic hysteroscopy and concurrent endometrial biopsy should be used as complementary diagnostic and therapeutic approach, especially for patients with previous IVF failures.

Alterations in uterine hemodynamics caused by uterine fibroids and their impact on in vitro fertilization outcomes.

ObjectiveTo investigate the impact of fibroids on the blood flow of the uterine and subendometrial arteries and in vitro fertilization (IVF) outcomes.MethodsIn this study, we analyzed 86 IVF/intracytoplasmic sperm injection (ICSI) cycles in which a gonadotropin-releasing hormone antagonist protocol was used for controlled ovarian stimulation between January 2008 and March 2009. The subjects comprised 86 infertile women with (fibroid group, n=43) or without (control group, n=43) uterine fibroids.ResultsPatient characteristics were similar between the fibroid and control groups. The IVF/ICSI outcomes in patients with fibroids were similar to those of patients in the control group. The resistance index (RI) and pulsatile index (PI) of the uterine and subendometrial arteries on the day of embryo transfer were also comparable between the two groups. IVF outcomes and uterine hemodynamics in patients with multiple (≥2) fibroids were similar to those of patients with a single fibroid. However, clinical pregnancy and implantation rates were significantly lower in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05). The RI and PI of the subendometrial artery were significantly higher on the day of embryo transfer in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05).ConclusionFibroids which distorting the uterine cavity might impair the subendometrial artery blood flow clinical pregnancy rate and embryo implantation rate in infertile patients undergoing IVF. Otherwise, IVF outcomes were not influenced by the presence of uterine fibroids.

A rare case of primary amenorrhea with two etiologies, hypothalamic amenorrhea, transverse vaginal septum, and no hematocolpos.

We reported a rare case of hypothalamic amenorrhea and transverse vaginal septum. A 28-year-old woman presented with primary amenorrhea and no complaint of abdominal pain. Laparoscopy revealed a small rudimentary uterus with streak ovaries and a vaginal pouch. The patient with diagnosis of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome was subjected to a vaginoplasty in another fertility center. In our institute, after two courses of estrogen and progesterone, sonography revealed hematocolpos, while, under anesthesia, transverse vaginal septum was resected. Hysteroscopy revealed normal uterine cavity. She became pregnant 5 months postoperatively with controlled ovarian stimulation (COS) in conjunction with intrauterine insemination, and she has two healthy babies now. This case highlights the importance of careful evaluation of all primary amenorrheas. Clinicians should be aware of presence of more than one etiology which causes atypical presentations and accomplishes a systematic strategy for the evaluation of amenorrhea potential to avoid long-term side effects of a misdiagnosis.