Office Hysteroscopy Research Articles

P-750 Clinical efficacy of virtual reality for acute pain and anxiety management during outpatient hysteroscopy and endometrial biopsy in subfertile patients

Abstract Study question Does the use of virtual reality (VR) headsets in diagnostic office hysteroscopy (HSC) with endometrial biopsy (EB) reduce anxiety and pain scores in the patient? Summary answer Virtual reality during office HSC do not seem to improve relaxation, anxiety, or pain scores. Physicians have a good perception of patients’ pain. What is known already Women undergoing outpatient HSC experience high levels of preoperative anxiety, which increase pain and discomfort during the procedure. The experience of pain is a complex phenomenon, which simultaneously occurs on cognitive, emotional, and behavioural levels, and is influenced by many factors. A Cochrane review failed to show a significant difference between different types of pain relief (analgesics, local anaesthetic and verbal support techniques …). VR is a multisensory immersion providing an interactive high level distraction, occupying a large portion of humans’ finite attentional resources (vision and audio), and leaving less cognitive capacity available to process pain. Study design, size, duration The sample size for this prospective randomized controlled trial was calculated at 196 patients (98 per group), considering a power of at least 80% to detect superiority of adding a VR headset versus standard care, standard deviation (SD = 2.0), using a two-sided, t-test, at significance level alpha of 0.05. The preliminary results after 1 month include a sample of 48 patients 25 in the VR group and 23 controls. Participants/materials, setting, methods All 48 patients suffer subfertility and underwent HSC with EB at our tertiary-care fertility center. We used Oncomfort®, a commercially available VR autohypnosis relaxation program designed for perioperative settings. The headmounted smartphone display with headphones provides image sound distraction with suggestive hypnosis techniques incorporated. Before and immediately after the exam, both patients and surgeons fill out a questionnaire using the 10.0cm visual analog scale (VAS). Main results and the role of chance The mean duration of HSC was 3min43sec in the VR group, (range 2-6min), compared to 4min50 in the control group (range 1-12minutes), which was not significantly different (p = 0.09). Subjective variables of stress, anxiety and pain were evaluated at four different time points, i.e. before, during, immediately after HSC and one week later. According to VAS, stress levels did not differ significantly (p > 0.05) between the VR group and the control group, or within time 5.08 to 5.36 to 3.08 vs 4.48 to 4.83 to 2.48 before, during and after HSC respectively. Fear levels prior to HSC at 4.28 for VR patients and 3.52 for controls did not increase significantly during HSC in both groups: 4.44 vs 4.17. During HSC, pain levels increased from 1.40 to 4.720 in the VR group vs 0.65 to 4.109 (NS) in the controls, to decrease again afterwards to 2.60 vs 2.17 (NS) respectively. Physicians rated the average pain levels of VR patients as 3.32 compared to 3.0 for controls, which was significantly correlated to patients’ perception (p < 0,005). Patients gave a positive rating to the VR experience (satisfaction score 7.17). Limitations, reasons for caution These are preliminary results, evaluating only a fourth of the required sample. A population selection bias could exist, as recruited patients were willing to accept VR. The very short induction period of 2 minutes could influence the effect of (immersiveness into) VR. Wider implications of the findings Pain management in ambulatory procedures should be multimodal and should include both pharmacological and non-pharmacological interventions. Introducing VR might increase patient tolerance for longer or more painful procedures. Offering a range of options will increase the spectrum of successful procedures in the outpatient setting and improve patient experience. Trial registration number B.U.N. 1432020000050

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial

To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women. Randomized, double-blind trial. Tertiary referral hospital. A total of 180 nulliparous women undergoing diagnostic OH. We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group. The primary outcome was pain during OH measured using a 100-mm visual analog scale (0=no pain; 100=worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p=.1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p=.003, and p <.001, respectively). Side effects were comparable in both study groups. Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.

Endometrial polyps with increased plasma cells are associated with chronic endometritis in infertility patients: Hysteroscopic findings and post-polypectomy pregnancy rates.

PurposeThe relationship between endometrial polyps (EPs), chronic endometritis (CE), hysteroscopic findings, and antimicrobial in infertility patients was determined.MethodsWe retrospectively enrolled 115 infertility patients with suspected EPs who underwent office hysteroscopy. Patients were divided into 3 groups: 38 with increased plasma cells in EPs (group 1); 31 without increased plasma cells in EPs (group 2); and 46 without EPs (group 3). The 3 groups underwent hysteroscopy with or without polypectomies, and immediately thereafter, an endometrial aspiration biopsy (EAB) was performed. CE was diagnosed based on plasma cell infiltration in the non‐polypoid endometrium obtained by EAB.ResultsThe percentage of CE was 68.4%, 32.2%, and 28.3% in groups 1, 2, and 3, respectively. CE was more frequent in group 1 than group 2 or 3 (P = .01 and P = .002, respectively). The number of polyps was higher in group 1 than group 2. After adjustment for age and assisted reproductive technology, antibiotic therapy was not associated with pregnancy (adjusted odds ratio, 0.44; 95% confidence interval, 0.05‐3.57) in patients with EPs and CE.ConclusionsGroup 1 was associated with CE, and hysteroscopic findings were different from group 2. Antibiotic therapy after polypectomy for EPs with CE may not always be necessary.

Hysteroscopic detection of chronic endometritis: Evaluating proposed hysteroscopic features suggestive of chronic endometritis

PurposeTo evaluate the proposed criteria in a large sample and in additional subgroups in order to test the validity of the hysteroscopic features widely-accepted as suggestive of CE. Method(s)All patients (n: 2675) underwent outpatient hysteroscopy, with the vaginoscopic approach technique. Hysteroscopic features such as, stromal oedema, diffuse or focal hyperaemia, “strawberry aspect”, micropolyposis and endometrial polyps, are often indicate the presence of chronic endometritis. All hysteroscopic features, alone and in combination were applied in 7 (seven) different subgroups of the sample: total sample, women in reproductive age, women with infertility issues/IVF screening, women with history of recurrent miscarriages, menopausal women, and women with hysteroscopic indication of Abnormal Uterine Bleeding (AUB) in women of reproductive age and postmenopausal bleeding (PMB). From each case, endometrial samples were obtained and immunohistochemistry, identifying CD-138, was applied in order to diagnose CE. Result(s)A total of 2675 patients were included of which, 1444 women were found with at least one of the proposed hysteroscopic features mentioned above. Stromal oedema, focal or diffuse hyperaemia and “strawberry aspect” in combination with micropolyposis demonstrated higher rates of diagnostic accuracy in the detection of CE correlated to histologic confirmation. Micropolyposis, stromal oedema, focal or diffuse hyperaemia and “strawberry aspect” offer great diagnostic accuracy in the hysteroscopic detection of Chronic Endometritis, regardless reproductive status and/or clinical presentation. Endometrial polyps are not valid hysteroscopic features in cases of suspected CE. Conclusion(s)Diagnostic hysteroscopy can accurately diagnose cases of CE, based on stromal oedema, focal or diffuse hyperaemia and “strawberry aspect”, in combination with micropolyposis. In subgroups of infertile women, higher diagnostic accuracy based on the hysteroscopic features mentioned, was more likely to be achieved. Whether endometrial polyps are suggestive of CE, when identified during office hysteroscopy, remains controversial.

Systematic review of the safety and efficacy of tramadol during office hysteroscopy

Office hysteroscopy (OH) is a common procedure in gynecology. Pain is the most frequently reported problem in OH. In this study, we aimed to investigate the role of tramadol administration in relieving pain in women undergoing OH. We searched PubMed, the Cochrane Library, ClinicalTrials.gov, MEDLINE, Scopus, and Web of Science databases for relevant clinical trials based on our search terms. We included randomized controlled trials and included all published trials in all six searched databases from their inception until February 28th 2021.We included pain as the primary outcome, and the incidence of adverse events of tramadol as secondary outcomes. We performed the analysis of continuous data using mean difference (MD) and dichotomous data using risk ratio (RR). We found that tramadol led to significantly less pain during the actual procedure [MD=-1.27, 95% confidence interval (CI): (-1.66, -0.88); p<0.001], immediately after the procedure [MD=-1.03, 95% CI: (-1.40, -0.67); p<0.001], and 30 minutes after the procedure [MD=-0.74, 95% CI: (-1.06, -0.41); p<0.001]. Regarding safety endpoints, no significant difference was noted for dizziness [RR=1.88, 95% CI: (0.79, 4.47); p=0.16] or vomiting [RR=1.80, 95% CI: (0.40, 8.18); p=0.45]. Based on the available data, we conclude that tramadol administration seems to be both effective and safe for patients undergoing office hysteroscopy.

Warm distension fluid reduces pain severity in office hysteroscopy: a randomized controlled trial.

BACKGROUND: Abnormal uterine bleeding (AUB) affects approximately 14% to 25% of women of reproductive age. The most common use of office hysteroscopy is to evaluate pathologies related to AUB and reproductive health, but office hysteroscopy can also be used for the diagnosis and treatment of other intrauterine pathologies.OBJECTIVE: Investigate the effects of the temperature of the distension fluid on pain severity in patients undergoing diagnostic office hysteroscopy due to AUB.DESIGN: Randomized controlled clinical trial.SETTING: Tertiary care center in Turkey.PATIENTS AND METHODS: One hundred perimenopausal patients with AUB were randomly allocated according to the temperature of the distension fluid used in office hysteroscopy (37°C or 25°C). Pain intensity was assessed using a visual analog scale (VAS). Six VAS measurements were compared over the course of the hysteroscopy: pre-treatment (VAS-1), at vaginal entry (VAS-2), at the cervical ostium transition (VAS-3), while in the cavity (VAS-4), at the end of the procedure (VAS-5), and 30 minutes after the end of the procedure (VAS-6).MAIN OUTCOME MEASURE: VASSAMPLE SIZE: Fifty in each group enrolled, one drop out.RESULTS: The VAS-3, VAS-4, and VAS-5 scores were significantly lower for patients in the warm fluid group than in the room temperature group (P<.05), whereas the VAS-1, VAS-2, and VAS-6 scores were similar in both groups.CONCLUSION: The application of warm distension fluid in office hysteroscopy reduces pain severity compared with the application of an unheated fluid.LIMITATIONS: The main limitations of the study were that a subgroup analysis could not be performed due to an insufficient number of cases, and we were unable to evaluate vasovagal symptoms.CONFLICT OF INTEREST: None.

Crisis Management of Hysteroscopic Surgical Complications in the Office Setting.

As health care providers are increasingly motivated to perform office procedures, there is marginal training and attention related to crisis management (CM). We review the CM in office gynecology and illustrate the value of applying the STOP (stop, think, observe, plan) mental framework to acute management of office hysteroscopy complications. We performed a literature review on crisis management in gynecology. Concepts of team leadership, simulation training, awareness of human error, and panic control are implemented in CM. Health care providers need to be cognizant of the importance of CM for optimizing patient safety and quality improvement and consider its application on office-based procedures. Crisis management has become increasingly relevant in the outpatient setting, seeking to better equip physicians with the skills to manage adverse outcomes while performing office-based procedures.

Traitements des synéchies associées à une infertilité

Synechiae are intrauterine adhesions that affect the fertility of women. They are most often of post-traumatic origin. The management of pregnancy abortions in the first trimester and post-delivery retention are the main contributing factors. Synechiae is responsible for cycle disorders and repeated pregnancy loss. Hysteroscopy is the reference method for its diagnosis and treatment. The surgical objective is the restoration of a normal sized cavity and a functional endometrium to allow fertilization and implantation. The use of small diameter (5mm) hysteroscopes and no energy or bipolar energy instruments are recommended. Echo guidance facilitates the treatment of severe synechiae and limits the risk of intraoperative perforation. The main risk of treatment is recurrence, particularly in severe cases where multiple operating times are sometimes necessary. An office hysteroscopy at 6 weeks is recommended to identify and treat these recurrences. Different physical, molecular or cellular methods are studied as primary and secondary prevention of postoperative synechiae. The objective of this review is to provide an update on the treatment of synechiae in the context of infertility.

Transvaginal Sonography Post–Office Hysteroscopy as a Screening Tool for Tubal Patency: A Reliable and Feasible Technique in an Outpatient Setting

To determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP). We conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated. Pelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10-50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P=0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10-50 mL vs. 3.8% with 60-190 mL and 1.3% with 200-760 mL; P=0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n=60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P=0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy). TVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.

Sonographic and Hysteroscopic Assessment of Uterine Congenital Malformations: A Retrospective Study

Aim: Congenital uterine malformations are often diagnosed via Transvaginal Sonography (TVS) and/or office hysteroscopy. Few studies address the diagnostic accuracy of both techniques in detecting these abnormalities. The aim of this study is to evaluate sonographic and hysteroscopic findings in women with uterine congenital malformations. Methods and Materials: A nested retrospective study on 137 medical records of women with congenital malformations undergoing vaginoscopic office hysteroscopic and transvaginal sonographic assessment in the Endoscopic Unit, Department of Gynaecology, University Hospital of Ioannina, Greece was conducted. All women were examined initially via Transvaginal Sonography (TVS) and the sonographic findings were correlated with the hysteroscopic findings. Women with septate or bicornuate uteri confirmed their pathology through laparoscopy, a proposed gold standard technique. Result: Hysteroscopy was able to detect 136 out of 137 cases of congenital malformations with a false positive bicornuate uterus. Transvaginal sonography (TVS) showed moderate diagnostic accuracy accompanied by positive predictive value (PPV) at 79.79%, negative predictive value (NPV) at 99.17%, sensitivity at 79.79%, and finally specificity at 99.17%. Endometrial thickness assessed by TVS was found to be higher in cases of complete septate and bicornuate uteri. The incidence of congenital malformation within the total population was estimated at 4.56%. Conclusion: Diagnostic hysteroscopy is a reliable tool in detection uterine congenital malformations compared to two-dimensional sonography. Office hysteroscopy demonstrates high diagnostic accuracy and should replace traditional sonographic assessment in determining congenital uterine malformations. Clinical significance: Hysteroscopy is superior than TVS in detecting uterine congenital malformations.

Office hysteroscopy before first in vitro fertilization. A randomized controlled trial

BackgroundImplantation failure remains a mystery since decades. This procedure needs a “top quality embryo” and a “normal” uterine cavity. To assess uterine cavity before first in vitro fertilization (IVF), many diagnostic tools could be used. Hysteroscopy remains the gold standard to diagnose and treat intra-uterine anomalies. However, it is not clearly recommanded to offer an office hysteroscopy before first IVF when transvaginal ultrasound (TVUS) and hysterosalpingography (HSG) were normal. PurposeThis study aimed to assess the role of office hysteroscopy before first IVF when no intra-uterine anomalies are suspected. Basic proceduresWe conducted a randomized controlled trial including 171 women scheduled for their first IVF. Women were assigned to either Group I: office hysteroscopy before IVF or Group II: immediate IVF.We included women aged less than 40 years, having regular cycles, FSH levels less than10UI/l, antral follicular count ≥12, normal TVUS and HSG. Their body mass index (BMI) ranged from 19 to 30 kg/m2. We excluded patients known having severe endometriosis, polycystic ovarian syndrome (PCOS) and oocyte receivers. The primary outcome were livebirth rate and clinical pregnancy rate. Main fundingsBetween january 2016 and september 2017, we randomly assigned 171 women to either Group I (n = 84) or Group II (n = 87). Hysteroscopy was done in the mid-follicular phase immediately before IVF. Baseline characteristics and IVF features were comparable between groups except for the IVF protocol. Live birth rate was 23,9% in Group I versus 19,3% in Group II. (p = 0,607). Clinical Pregnancy rate was 32,4% in Group I versus 21,7% in Group II. (p = 0,326). No statistical significance was observed for neither miscarriage rate nor multiple pregnancy rate. Hysteroscopy showed 30% unsuspected intra-uterine anomalies: 11 intra-uterine adhesions, 7 polyps, 7 clinical endometritis and one fibroid print. Therapeutic hysteroscopy was done only for 6 intra-uterine adhesions and 3 polyps. Other anomalies did not require operative hysteroscopy. Visual analog score during hysteroscopy was 4,69 +/-2,892. 5 women (6%) of Group I experienced discomfort during diagnostic hysteroscopy. Only one patient had vagal syncope. No further complications were observed. Principal conclusionsOffice hysteroscopy before first IVF seems not improve IVF results. Minimal intra-uterine anomalies not diagnosed by transvaginal ultrasound and hysterosalpingography do not seem to reduce IVF results.

Endometrial scratching for poor responders based on the Bologna criteria in ICSI fresh embryo transfer cycles: a preliminary retrospective cohort study

Objective:This study evaluated the effect of endometrial injury on pregnancy outcomes in patients with a poor ovarian response (POR), based on the Bologna criteria, who underwent intracytoplasmic sperm injection (ICSI) cycles.Material and Methods:Sixty-eight patients were enrolled in this retrospective cohort study. All patients in the endometrial scratching group (group 1, n=32) and control group (group 2, n=36) underwent office hysteroscopy in the early follicular phase of the cycle before controlled ovarian stimulation. Group 1 also underwent endometrial scratching. The main outcome measure was the ongoing pregnancy rate.Results:The study groups had similar baseline demographics, including age, body mass index, duration of infertility, number of ICSI cycles, and hormone levels. However, the antral follicle count was significantly higher in group 1 than in group 2 (4.2±1.9 vs 3.3±1.8; p<0.05). There were no significant group differences in ovarian stimulation characteristics (ovarian stimulation time, trigger day endometrial thickness, number of metaphase II oocytes), number of embryos transferred, or the ratio of embryo transfer on days 3 and 5. Moreover, there were no significant differences between groups 1 and 2 in the rates of chemical pregnancy (25% vs 19.4%), clinical pregnancy (15.6% vs 11.1%) or ongoing pregnancy (9.4% vs 8.3%) (p>0.05 for all).Conclusion:Endometrial scratching did not improve pregnancy outcomes for patients meeting the Bologna criteria for a POR to ICSI cycles using fresh embryo transfer and the GnRH antagonist protocol.

Three-dimensional ultrasonography versus office hysteroscopy for the evaluation of uterine cavity and cervical canal before IVF

Three-dimensional ultrasonography versus office hysteroscopy for the evaluation of uterine cavity and cervical canal before IVF

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial.

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures. This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure. Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01). Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation. ClinicalTrials.gov , NCT04415489.

Peculiarities of treatment and prevention of recurrences in women with intrauterine pathologies

The study is devoted to the problem of surgical treatment, rehabilitation program and prevention of recurrences in intrauterine pathologies (polyposis and uterine adhesion) in women with reduced reproductive potential. The urgency of this problem is characterized by a high frequency of abnormal uterine bleeding, hypomenstrual syndrome and amenorrhea, infertility and miscarriage. Clinical data include the own experience of treatment and rehabilitation of 66 patients; women with intrauterine synechiae (32 people) were included in group 1; 34 patients with hyperplastic form of chronic endometritis and polyposis were included in group 2. The control group included 30 healthy patients without gynecological pathology and menstrual irregularities. All women underwent therapeutic hysteroscopy with adgeolysis and polypectomy. In the postoperative period, 24 patients of the main group received the proposed program to restore the endometrium and its implantation potential. The comparison group included 42 patients with general principles of postoperative management. The key points of the proposed program were: immunomodulatory therapy, hormone replacement therapy and the use of autoplasma. As a result of the study, a reduction in the recurrence of the adhesive process was proved, as well as a significantly higher number of cases of pregnancy. Thus, for the comprehensive treatment of intrauterine pathology in young women with reduced reproductive potential it is important not only to use minimally invasive office hysteroscopy, an active postoperative rehabilitation period is of great importance too.

Expression and Potential Role of MMP-9 in Intrauterine Adhesion.

Objective Intrauterine adhesions affect menstruation and fertility, and endometrial fibrosis is the final manifestation of IUA. MMP-9 is closely related to fibrosis. The purpose of the study was to assess the role of MMP-9 in intrauterine adhesion (IUA) in rats and patients. Methods 40 rats and 24 women were enrolled in this study. 40 rats were randomly divided into 3 groups: IUA group (n = 20), sham group (n = 10), and control group (n = 10). Rat IUA models were established by intrauterine mechanical and chemical injured. In this study, 12 patients of intrauterine adhesions were detected and underwent TCRA (transcervical resection of adhesion) surgery, and endometrial tissue specimens were obtained during operation. One month later, an office hysteroscopy procedure was performed, and endometrial tissue specimens were obtained during operation again (postoperative group). A group of 12 normal age-matched control individuals served as controls underwent hysteroscopy and endometrial sampling. We used immunohistochemistry to detect MMP-9 expressions in rats and human endometrial tissues and to detect MMP-9 protein levels by Western blotting. In addition, we detected mRNA expression levels with qRT-PCR. Results The expression of MMP-9 in the IUA rats was reduced compared with that in the sham group and Ctrl group (P < 0.05), and the expression of MMP-9 was also reduced in the IUA patients compared with that in the Ctrl group (P < 0.05). The mRNA levels of MMP-9 in the endometrium reflected similar results (P < 0.05). The MMP-9 clearly increased even in the endometrium after TCRA surgery (P < 0.05). Conclusion Our study suggests that MMP-9 may play an important role in IUA. In the future, more in-depth research should be conducted on MMP-9.

Identifying the risk factors and incidence of Asherman Syndrome in women with post‐abortion uterine curettage

AbstractAimTo evaluate the risk factors and incidence of Asherman Syndrome in women with post‐abortion uterine evacuation and curettage.MethodsA total of 2546 patients who had surgical abortion (uterine evacuation and curettage) before the 20th gestational week with indications of missed abortion, anembryonic pregnancy, incomplete abortion, and elective curettage in a tertiary antenatal care center were recruited. The patients were called and surveyed for their symptoms; including infertility, oligo‐amenorrhea and recurrent pregnancy loss, preterm birth and intrauterine growth retardation and abnormal placentation as criteria of Asherman Syndrome. Diagnostic (office) hysteroscopy was performed for 177 who had one of those complaints.ResultsThe incidence of Asherman Syndrome was 1.6% (n = 43/2546). History of ≥3 abortions was the main factor that increased the risk of Asherman Syndrome for by 4.6 times. Use of vacuum aspiration or sharp curettage, premedication for cervical priming, and having a pregnancy &gt;10th gestational weeks were not risk factors for Asherman Syndrome.ConclusionWhen the diagnosis was based on presence of symptoms who underwent uterine instrumentation, the incidence of Asherman Syndrome was found to be 1.6%. Repeated abortions were the main risk factor for Asherman Syndrome and avoiding from repeated uterine instrumentations may have a role in prevention.

Assessment of Tubal Patency with Selective Chromopertubation at Office Hysteroscopy versus Modified Minilaparoscopy in Infertile Women.

Objectives:Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.Materials and Methods:The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, “Visualizable flow” at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.Results:All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93–0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.Conclusion:OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.

Doula support in office hysteroscopy: results from a pilot study

Background: This pilot study aimed to evaluate the feasibility of doula support in office hysteroscopy and the potential effectiveness of doula support during office hysteroscopy to reduce anxiety and pain. Methods: Twenty-eight women, median age 43.5 (range 21–73), with indications for office hysteroscopy received doula support (intervention) or routine care (control group) during the procedure. Feasibility was measured in terms of successful office hysteroscopies, duration, and adverse events. Outcome measures were Spielberg State-Trait Anxiety Inventory-S (STAI-S), and the Numeric Rate Scale (NRS) for pain intensity. Results: The results showed similar success rates, duration, and adverse events between the groups, with no differences in reported pain intensity. Both groups had high, comparable levels of anxiety before the procedure (Doula group mean STAI-S score = 45.4, control group = 45.8). After the procedure, the doula group showed slightly increased anxiety while the control group showed slightly decreased anxiety. There was a significant difference between groups favoring the control group when comparing STAI-S mean score post-procedure (48.6 in the Doula group versus 44.1 in the control group p = 0.033). However, when analyzing the mean change across groups (p = 0.205) that difference was not significant. Discussion: To conclude, this pilot study suggests that Doula support may be feasible but not superior to routine care support in office hysteroscopy. High anxiety levels may be more relevant than pain during the procedure. Further investigation of the state and trait anxiety in office hysteroscopy populations in different health care contexts is recommended.

Detection of intracavitary lesions in 436 infertile women by office hysteroscopy and comparison with histopathology results

Aim: To examine the importance of office hysteroscopy in detecting and treating endometrial pathologies of infertile patient groups.Materials and Methods: For this retrospective observational study, first, electronic hospital records were examined in order to identify patients who underwent office hysterescopy at our clinic, between 2003 and 2020, for infertility. The office hysteroscopy findings of 436 patients were included in the study, and examined and compared with the histopathological results.Results: The age distribution of the patients included in the study was homogeneous in terms of group variances. Thehysteroscopy findings of the patients were as follows: normal cavityin 137 patients(31.4%), endometrial polyps in 199 patients(45.6%), synechia in 14 patients(3.2%), subseptum or arcuate uterus in 32 patients (7.3%), t-shaped uterus in 28 patients (6.4%), cervical polyps in 6 patients (1.4%), Asherman’s syndrome in 6 patients (1.4%), and submucous myoma in 14 patients (3.2%). The most frequently detected lesion with office hysteroscopy was polyps,at a rate of 47% with 205 patients. In the pathology results, of the 137 patients who were diagnosed with normal endometrium via office hysteroscopy and underwent biopsy, 119were reported as normal (89.6%), while 6 were diagnosed with polyps (4.4%). The sensitivity and specificity of office hysteroscopy in detecting endometrial polyps were 94% and 56%, respectively.Conclusion: Office hysteroscopy may be one of the first alternative methods that can be used for safe and practical outpatient diagnosis and treatment in infertile patient groups.