ASRM Video article: Hysteroscopic removal of IUD in pregnancy

The use of Intrauterine Devices (IUD) has increased in recent years. Used correctly, the failure rate for IUD is less than 1%. If a patient gets pregnant with IUD in place, the risk of adverse outcomes like spontaneous abortion and preterm birth increases many-fold.

WHO advises removal of IUD at the earliest gestational age possible if strings are visible on vaginal examination. If strings are not visible there are 3 ways to manage a case of IUD with pregnancy:

Expectant management

Removal with a grasper under ultrasound guidance

Removal under hysteroscopic visualization

Here is a recent video-article published in December issue of Journal Fertility and Sterility, showing step by step procedure of hysteroscopic removal of IUD in 4 patients. In all four cases, the strings were not visible during a vaginal examination. After removal of IUD, all patients had uneventful live term delivery.

All patients were informed about the risk of the procedure, although negligible–– including rupture of gestation sac and pregnancy loss, consent obtained, viability and location of IUD confirmed by pre-op ultrasound and prophylactic antibiotics given. The actual procedure includes:

Vaginoscopic hysteroscopy

IUD localization with or without imaging guidance

Removal of the IUD with the help of hysteroscopic grasper

The key is to use slender hysteroscope and use the minimal amount of distention media. The method is safe with minimum procedure-related complications and > 90% ongoing pregnancy rate.

Here is the American Society for Reproductive Medicine (ASRM) video showing step by step procedure of hysteroscopic removal of IUD in 4 patients. 

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Hysteroscopic management of symptomatic cesarean scar defects

https://openi.nlm.nih.gov/faq.php#copyright

The incidence of cesarean scar defect is on the rise with a rising cesarean delivery rate. According to the Center for Disease Control, the current cesarean section rate in the US is 31.9%.

For many years, cesarean scar defect was an accidental finding on hysterosalpingogram and pelvic sonogram, but since last two decades, it has been associated with post-menstrual spotting and bleeding.

The collected blood may result in inflammation leading to chronic pelvic pain, dysmenorrhea, dyspareunia, and vaginal discharge. It also causes secondary sterility possibly because of change in the endometrial milieu which lead to altered cervical mucus, sperm transport and interfere with embryo implantation. It is also responsible for obstetrical complications including abnormal placentation, scar dehiscence, and uterine rupture.

It was in the early 2000s when studies reported resolution of symptoms following surgical management of the defects. Three different routes have been described for the surgical management of cesarean scar defect or isthmocele: laparoscopic; hysteroscopic (when the residual myometrium is equal to or > 3 mm); and vaginal.

No randomized controlled trials have been published to establish the efficacy of one method over another. Some surgeons favor the hysteroscopic method because of its minimally invasive nature, quick recovery, and better resolution of symptoms. Complications involve injury to bladder, incomplete repair and persistence of symptoms.

To avoid these complications most surgeons, prefer this method when the residual myometrium is 3 mm thick or do the repair under ultrasound guidance. A randomized trial by Vervoort et al., comparing hysteroscopic repair vs., expectant management has shown significant improvement in pain and post-menstrual spotting after the repair.

Gubbini et al., have published two case series evaluating the efficacy of hysteroscopic repair of isthmocele in the resolution of postmenstrual symptoms and treatment of secondary infertility.

In the first series all 41 patients (100%) patients conceived with 24 months of completion of hysteroscopic isthmocele repair and in the second series, 26 patients with the defect underwent repair, of whom 7 out of 9 patients with secondary infertility became pregnant.

Those doing laparoscopic repair argue that this approach results in complete and proper resection of the scar tissue followed by the proper approximation of the overlying myometrium. Antagonists argue that the procedure is more invasive and has the inherent risk of bladder injury during separation along with incomplete resolution of symptoms. Evidence so far has demonstrated both methods to be equally effective in reducing symptoms and improving fertility.

In the August issue of Journal Fertility and Sterility, Sanders and Murji have presented two case series with a meticulous video showing hysteroscopic resection of the cesarean scar defect. The video begins with definition, symptoms, and identification of cesarean isthmocele and then proceeds to describe the two cases.

The video systematically identifies the anatomy, resecting the defect cephalad and then caudad, and ablation of the defect at its base.

Here is the video about Hysteroscopic Repair of Cesarean Scar Isthmocele

Flashback: Laparoscopic repair of Cesarean Scar Isthmocele

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Ten simple safety tips to avoid complications during hysteroscopy

Courtesy: Hysteroscopy newsletter

A series of precautions taken during before, during and after the hysteroscopic surgery can considerably reduce the risk of complications — reports Dr. Alice Rhoton-Vlasak, MD, Division of Reproductive Endocrinology & Infertility, from the University of Florida in the recent Hysteroscopy newsletter.

Hysteroscopy has evolved from merely a diagnostic procedure to method of choice for surgical treatment of intrauterine pathologies. Pantoleoni performed the first hysteroscopy using Desormeaux hysteroscope in 1869, and since then the development of hysteroscopy has flourished. 

With the increasing number of endometrial ablations, morcellation, electrosurgical procedures, and hysteroscopic sterilization performed worldwide, hysteroscopy has finally found its well-deserved niche in gynecological armamentarium.

It is generally a low-risk technique that utilizes the body’s natural passage to gain entry inside the uterine cavity. But like every surgical procedures complication are known to happen. These can be further reduced by taking simple precautions and being familiar with equipment and distention media.

Before the start of the procedure, the patient should be positioned appropriately to avoid nerve injury because the actual surgical time may be longer than the estimated time.

To avoid uterine perforation under challenging cases like Asherman’s syndrome or sizeable submucosal myoma, always use synchronous laparoscopic or ultrasound guidance.

The light source, suction and irrigation systems should be checked for smooth working before the start of the procedure. A backup set of instruments should be available in case of any intra-operative emergency.

Cervical dilatation should be cautiously performed, and precaution should be taken to avoid endometrial trauma and perforation. Hysteroscopic dilation of the cervix using the scope and hydrodistension is ideal.

Flushing air from tubes easily avoids air embolism, and it is always advisable to stop the procedure to purge the air out during the change of bags. The patient should not be put in Trendelenburg position during cervical dilatation and the hysteroscopic procedure to avoid a suction that may draw air into the uterine cavity.

Insert the hysteroscope cautiously inside the uterine cavity to avoid the formation of false passage in the cervix.

Hemorrhage during the hysteroscopic surgery is preventable with the use of electrosurgical coagulation, injection of vasopressin into the cervical stroma or the use of a Foley catheter balloon to exert intrauterine tamponade.

Avoid fluid overload by keeping a strict record of ins and out, limiting excess fluid absorption, and use of isotonic solutions in healthy individuals. Special precautions should be taken in older patients and those with heart failure or renal insufficiency.

A preoperative pelvic examination before the start of procedure gives a good idea of the uterine position. If the hysteroscope is in and the uterus fails to distend any time— a possibility of uterine perforation should be kept in mind. Stop the procedure immediately, and laparoscopy may be needed to assess the damage.

If any of the new morcellators or electrosurgical devices are introduced during a procedure, the entire surgical team should be aware of their functioning.

Following this simple safety tips can reduce the rate of hysteroscopic complications considerably. Besides, the patient should be made aware of all the risks before scheduling the procedure, and informed consent should be obtained.

Hysteroscopy Newsletter

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Enjoy the latest issue of Hysteroscopy Newsletter: Nov-Dec 2017

The use of hysteroscopy is increasing throughout the world and is currently considered the gold standard for the diagnosis and treatment of pathologies of the uterine cavity and more recently for some pathologies of the cervix and vagina. Technological progress is opening new horizons for hysteroscopy allowing the gynecologist to perform many surgical procedures safely and effectively in an outpatient setting without significant inconvenience to the patient based on the concept of "see and treat".

Enjoy and update yourself on some interesting topics in Hysteroscopy in this latest newsletter:

Adenomyosis

INTERVIEW WITH... Prof. Mark Hans Emanuel.

CASE REPORT Uterine Malformation

HYSTEROSCOPY Devices -Harpoon

Hysteroscopy Conundrums Is the uterine septum "mostly" avascular?

WHAT'S YOUR DIAGNOSIS?

Brief Review Hysteroscopy complication: false passage

Brief Review: Chronic Endometritis (I)

(Download It and Share it)

http://www.hysteroscopy.info/4/upload/hysteroscopy_newsletter_vol_3_issue_6_english.pdf

Hologic, Inc launched MyoSure MANUAL, for in-office intrauterine tissue removal

Hologic, Inc today expanded its Myosure portfolio by adding the MyoSure MANUAL device which enables physicians to more easily resect and remove intrauterine polyps and fibroids in office settings when used along with the MyoSure hysteroscope.

The device comes with an ergonomically designed blade that can be rotated through 360 degrees, enabling wide range of smooth motion. The system does not require cauterization and have a transparent tissue trap that allows the physician to see the specimen and can holds up to 4gms of tissue.

The tissue trap can be detached, and the specimen can be sent for direct histopathological examination.

In addition, the system also comes with a built-in vacuum, eliminating the need of external suction and works with a one-liter saline bag. 

The complete MyoSure system is a minimally invasive hysteroscopic treatment for women with Abnormal Uterine Bleeding (AUB) due to polyps or fibroids and requires no cauterization, which preserves uterine form and function.

Edward Evantash, M.D., Medical Director and Vice President of Medical Affairs, Hologic said in a press release, “We recognize the increased demand for in-office procedures, and seek to develop innovative solutions to provide flexibility and convenience for both physicians and patients. The MyoSure MANUAL device was designed for in-office tissue removal procedures, requiring minimal setup and no vacuum or fluid management system, while offering direct visualization when used with the MyoSure hysteroscope."

 “The MyoSure MANUAL device is an exciting addition to Hologic's growing portfolio of gynecologic solutions, developed with the patient and physician in mind. This addition to the MyoSure product suite signals our ongoing commitment to providing effective surgical solutions that can be performed in office to address our customers' needs and improve the overall patient experience," added Sean Daugherty, President of GYN Surgical Solutions at Hologic.

Contraindications for the use of MyoSure MANUAL Tissue Removal Device includes  pregnancy or suspected pregnancy, has clinical evidence of an active pelvic infection or history of a recent pelvic infection, or has cervical malignancies or previously diagnosed uterine cancer.

Other devices in Myosure Portfolio include MyoSure^®, MyoSure^® REACH, MyoSure^® XL, and MyoSure^®LITE devices.

Complete MyoSure MANUAL device Instructions for use

Press Release

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New treatment option for recurrent implantation failure on the horizon: Short term copper IUD

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Placement of Cu-IUD during hysteroscopy for two cycles can up the pregnancy rates in patients with RIF says results of a study published in July issue of Journal Fertility and Sterility.

Recurrent Implantation Failure (RIF) is very frustrating for patients and physician both. Over the decades, few research study have emerged forward about the etiology and therapeutic options.

 Constitutive, as well as mature defects of endometrium have been put forward as one of the etiology.

Treatments have largely been costly and empirical, mainly consisting of hysteroscopy, controlling endometrial infections, evaluating and treating any structural defects of the uterine cavity, changing the endometrial milieu, alternative medicines, Low molecular weight heparin and controlled endometrial injury and immunomodulation. 

Controlled endometrial injury or endometrial scratch has long been used as a treatment option in recurrent pregnancy loss. The injury results in increased vascularity and bring about implantation. However, a systematic literature review failed in establishing definite therapeutic benefits. Diagnostic hysteroscopy also works along the same line but still lacks robust evidence in its favor.

In this retrospective study Mao et al. from Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China have evaluated an offbeat approach for the treatment of RIF. 

The team of researchers placed Cu-IUD for two cycles in women with RIF while they were undergoing hysteroscopy.

They postulated that even after removing the IUD after two cycles, the altered endometrial environment because of foreign body persists much like the ‘endometrial scratch.’

The study recruited 440 women, with a history of at least two failed embryo transfers with good quality embryos. At the time of diagnostic hysteroscopy, the patients were offered a choice of getting a IUD for two months.

Out of which, 382 patients opted for IUD, while 58 patients refused the treatment option. All 382 patients underwent a repeat diagnostic and, if needed, therapeutic hysteroscopy followed by frozen embryo transfer cycle.

The demographics of both the groups were similar. Women who opted for IUD had a significantly higher implantation rate (29.29% vs. 16.56%), chemical pregnancy rate (53.25 vs. 41.38%), and clinical pregnancy rate (45.13% vs. 26.44%) than the non-IUD group.

After multivariate regression analysis, chemical pregnancy rates were significantly more in IUD users. It was also interesting to note a higher number of IUD users suffered from some kind of uterine pathology like polyps, endometritis and polypoid proliferations but, they did not affect the clinical pregnancy rate.

The study has several limitations in the way of sample size, selection bias and retrospective nature along with confounding effect of second look hysteroscopy in IUD users. The IUD use also may have prevented further adhesions formation in that group.

The question about the type of endometrial injury, duration of foreign body in situ and type of changes in the endometrium that is beneficial in increasing endometrial receptivity remain unanswered.

But, this study does bring forward a novel treatment option that is worth investigating in future.

Primary Source: Novel approach to recurrent implantation failure: short-term copper intrauterine device placement

Goodman, Linnea R. et al.

Fertility and Sterilit , Volume 108 , Issue 1 , 42 - 43

Intrauterine application of Hyaluronic Gel reduces adhesions after dilation and curettage for miscarriage

Intrauterine application of auto-crosslinked hyaluronic acid (ACP) gel after dilatation and curettage(D&C) for miscarriage in women with a history of at least one previous D&C reduces the incidence of intrauterine adhesions (IUAs) by nearly 57%, reports results of study published in recent issue of Journal Fertility &Sterility.

Termination of pregnancy is the most common obstetric procedure performed worldwide. Approximately 15-20% of clinically confirmed pregnancy end in miscarriage. According to a review published in European Journal of Contraception and Health Care 1 in 3 women will have at least one pregnancy terminated in her reproductive life span.

It is known that intrauterine adhesions form after D&C, but the exact prevalence is not known.

The current multicentric, patient and assessors blinded prospective trial called as Preventionof Adhesions Post Abortion (PAPA) study is the largest randomized trial conducted so far evaluating the effect of application of ACP gel.

It recruited 152 women who had suffered miscarriage before 14 weeks of pregnancy. The subjects also had previous history of either one miscarriage or Termination of pregnancy.

Women either received only D&C or D&C plus ACP gel. All women were scheduled for a follow-up diagnostic hysteroscopy at 8-12 weeks. 

IUA were observed in 13% of women who received ACP gel as compared to 30% women who did not receive the ACP gel. (RR= .43)

The authors concluded that use of ACP gel reduces the incidence of IUA by 57% in the specific subgroup of women undergoing D&C for miscarriage with a history of at least one D&C.

A Cochrane review have earlier concluded that additional studies are needed to study the effectiveness of other antiadhesive therapies for improving reproductive outcomes in infertile women treated by operative hysteroscopy.

The authors call for need of larger studies to confirm the current findings and evaluate the long term reproductive benefits (live-birth, pregnancy, and miscarriage rates) of decreasing the risk of adhesions formation.