Benedictus C. Schoot

An Alternative Approach for Removal of Placental Remnants: Hysteroscopic Morcellation

STUDY OBJECTIVE To evaluate our initial experience with hysteroscopic morcellation for removal of placental remnants. DESIGN Retrospective case series (Canadian Task Force classification II-3). SETTING University hospital and 2 teaching hospitals. PATIENTS Women with histologic confirmation of placental remnants after miscarriage, termination of pregnancy, or delivery. INTERVENTION From January 2005 to May 2010, hysteroscopic morcellation was used for removal of placental remnants. Retrospective review of medical records was performed. MEASUREMENTS AND MAIN RESULTS Analysis of 105 procedures was performed. In 99 procedures (94.3%), placental remnants were removed successfully at the first approach, and 90 procedures (85.7%) were without any adverse events. In 6 patients (5.7%), uterine perforation occurred, in 4 during cervical dilation and in 2 during the hysteroscopic procedure. Postoperatively, 3 patients had fever, 1 had hemorrhage, and 1 had abdominal pain. Routine second-look hysteroscopy in 23 patients revealed mild intrauterine adhesions in 1 patient (4.4%). CONCLUSION Hysteroscopic morcellation seems to be an effective technique for management of placental remnants. Future studies comparing various surgical treatment methods are needed to define factors that influence the ability to obtain the safest and most complete removal of placental remnants because this remains a challenging pregnancy-related condition.

Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial

BACKGROUND Hysteroscopy is often done in infertile women starting in-vitro fertilisation (IVF) to improve their chance of having a baby. However, no data are available from randomised controlled trials to support this practice. We aimed to assess whether routine hysteroscopy before the first IVF treatment cycle increases the rate of livebirths. METHODS We did a pragmatic, multicentre, randomised controlled trial in seven university hospitals and 15 large general hospitals in the Netherlands. Women with a normal transvaginal ultrasound of the uterine cavity and no previous hysteroscopy who were scheduled for their first IVF treatment were randomly assigned (1:1) to either hysteroscopy with treatment of detected intracavitary abnormalities before starting IVF (hysteroscopy group) or immediate start of the IVF treatment (immediate IVF group). Randomisation was done with web-based concealed allocation and was stratified by centre with variable block sizes. Participants, doctors, and outcome assessors were not masked to the assigned group. The primary outcome was ongoing pregnancy (detection of a fetal heartbeat at >12 weeks of gestation) within 18 months of randomisation and resulting in livebirth. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01242852. FINDINGS Between May 25, 2011, and Aug 27, 2013, we randomly assigned 750 women to receive either hysteroscopy (n=373) or immediate IVF (n=377). 209 (57%) of 369 women eligible for assessment in the hysteroscopy group and 200 (54%) of 373 in the immediate IVF group had a livebirth from a pregnancy during the trial period (relative risk 1·06, 95% CI 0·93-1·20; p=0·41). One (<1%) woman in the hysteroscopy group developed endometritis after hysteroscopy. INTERPRETATION Routine hysteroscopy does not improve livebirth rates in infertile women with a normal transvaginal ultrasound of the uterine cavity scheduled for a first IVF treatment. Women with a normal transvaginal ultrasound should not be offered routine hysteroscopy. FUNDING The Dutch Organisation for Health Research and Development (ZonMW).

Preconceptional low-dose aspirin for the prevention of hypertensive pregnancy complications and preterm delivery after IVF: a meta-analysis with individual patient data

STUDY QUESTION Does preconceptionally started low-dose aspirin prevent hypertensive pregnancy complications and preterm delivery in IVF patients? SUMMARY ANSWER The current data do not support the use of preconceptionally started low-dose aspirin treatment for the prevention of hypertensive pregnancy complications and preterm delivery in IVF women. WHAT IS KNOWN ALREADY Studies starting low-dose aspirin treatment as prevention in the second trimester of pregnancy found no or only moderate reductions in the relative risk of developing pre-eclampsia. Low-dose aspirin was possibly started too late, that is after the first episode of trophoblast invasion. STUDY DESIGN, SIZE, DURATION We performed a meta-analysis with individual patient data (IPD), in which four authors could provide IPD on a total of 268 pregnancies (n = 131 treated with aspirin, n = 137 placebo). Data on hypertensive pregnancy complications and preterm delivery were collected. PARTICIPANTS/MATERIALS, SETTING, METHODS All separate databases were merged into a summary database. Treatment effect of aspirin on the incidence of hypertensive pregnancy complications (n = 187) and preterm delivery (n = 180) were estimated with odds ratios (OR) and 95% confidence intervals (95% CI) using multivariable logistic regression. MAIN RESULTS AND THE ROLE OF CHANCE There were significantly fewer twin pregnancies in the aspirin group (OR 0.55 95% CI 0.30-0.98), but no significant differences for hypertensive pregnancy complications and preterm delivery: for singletons OR 0.62 (95% CI 0.22-1.7) and OR 0.52 (95% CI 0.16-1.7), respectively, as well as for twin pregnancies OR 1.2 (95% CI 0.35-4.4) and OR 1.6 (95% CI 0.51-5.0), respectively. LIMITATIONS, REASONS FOR CAUTION We have to bear in mind that the included studies showed clinical heterogeneity; there was variation in the duration of low-dose aspirin therapy and degree of hypertension between the different studies. Although we combined IPD from four studies, we have to realize that the studies were not powered for the outcome of the current IPD meta-analysis. WIDER IMPLICATIONS OF THE FINDINGS Based on the current meta-analysis with IPD we found no confirmation for the hypothesis that preconceptionally started low-dose aspirin reduces the incidence of hypertensive pregnancy complications or preterm delivery in IVF women. Larger studies are warranted.

Hysteroscopic morcellator system can be used for removal of a uterine septum

OBJECTIVE To evaluate whether the hysteroscopic morcellator (HM) can be used as an alternative for uterine septum removal. DESIGN Case report. SETTING Outpatient clinic of a university-affiliated teaching hospital (Catharina Hospital, Eindhoven, the Netherlands). PATIENT(S) A 34-year-old Asian woman with recurrent miscarriages and a large uterine septum and bicornuate uterus. INTERVENTION(S) Septum removal using the HM. MAIN OUTCOME MEASURE(S) Successful removal of a uterine septum. RESULT(S) Considering obstetric complications, septum removal was carried out. Currently, septum transection using the resectoscope is the gold standard. Instead of transection we achieved nearly complete removal of a septum, using the HM. CONCLUSION(S) The HM is a safe, effective, and easily manageable alternative for uterine septum removal compared with classic resectoscopy.

Hysteroscopy before In-Vitro Fertilisation (inSIGHT): A Multicentre, Randomised Controlled Trial

Since the first successful live birth after in vitro fertilization (IVF) was reported in 1978, more than 5 million children have been born with the help of this and intracytoplasmic sperm injection (ICSI) procedures. However, only approximately 25% to 30% of cycles of IVF and ICSI lead to the birth of a child. The reasons for implantation failure are poorly understood. One major cause of implantation failure is abnormalities of the uterine cavity such as polyps, myoma, and adhesions. Hysteroscopy has been generally regarded as the standard procedure to detect these uterine abnormalities. It is thought to improve pregnancy rates in women scheduled for IVF by detection and surgical removal of uterine cavity abnormalities, dilatation of the cervical canal, or induction of inflammatory reactions in the endometriumby the procedure itself. Hysteroscopy is often performed routinely in infertile women scheduled for their first IVF cycle. However, there are no data from well-designed randomized controlled trials to support this practice. The inSIGHT trial is a pragmatic multicenter randomized clinical trial designed to determine whether routine hysteroscopy before the first IVF treatment cycle increases the live birth rate. The trial was conducted in 7 university hospitals and 15 large general hospitals in the Netherlands. Women eligible for the trial were infertile, scheduled to start their first IVF or ICSI treatment, had no previous hysteroscopy, and had a normal transvaginal ultrasound of the uterine cavity. Subjects were randomly assigned in a 1: 1 ratio to hysteroscopy with treatment of detected intracavitary abnormalities before starting IVF followed by IVF (hysteroscopy group) or to immediate start of IVF treatment (immediate IVF group). Web-based randomization was done with a variable block size to allocate patients to groups and was stratified by center. The doctors, outcome assessors, and participants were not masked to the assigned group. The primary study outcome was an ongoing pregnancy (detection of a fetal heartbeat at > 12weeks of gestation) within 18 months of randomization and a live birth. Analysis was done according to intention to treat. Between May 25, 2011, and August 27, 2013, 750 women were randomized: 373 to the hysteroscopy group and 377 to the immediate IVF group. A live birth occurred during the trial period in 209 (57%) of 369 women in the hysteroscopy group and 200 (54%) of 373 in the immediate IVF group; the relative riskwas 1.06, with a 95% confidence interval of 0.93 to 1.20; P = 0.41. These findings demonstrate that hysteroscopy does not improve live birth rates in infertile women scheduled for their first IVF cycle, who have a normal transvaginal ultrasound of the uterine cavity. Therefore, routine hysteroscopy should not be performed in women with a normal transvaginal ultrasound.

Removal of Endometrial Polyps: Hysteroscopic Morcellation versus Bipolar Resectoscopy, A Randomized Trial.

STUDY OBJECTIVES To compare hysteroscopic morcellation with bipolar resectoscopy for removal of endometrial polyps, in terms of procedure time, peri- and postoperative adverse events, tissue availability, and short-term effectiveness. DESIGN Multicenter, open label, randomized controlled trial (Canadian Task Force classification I). SETTING Day surgery setting of a teaching and a university hospital. PATIENTS Women with larger (≥1 cm) endometrial polyps. INTERVENTIONS Hysteroscopic morcellation with the TRUCLEAR 8.0 Tissue Removal System or bipolar resectoscopy with a rigid 8.5-mm bipolar resectoscope. MEASUREMENTS AND MAIN RESULTS Eighty-four women were included in the intention-to-treat analysis. Median operating time was 4.0 min (range: 2.5-7.1) and 6.0 min (range: 3.8-11.7) in the hysteroscopic morcellation and resectoscopy groups, respectively. Operating time was reduced by 38% (95% confidence interval: 5%-60%; p = .028) in the hysteroscopic morcellation group. Procedure time, which was defined as the sum of the installation and operating time, tended to be less for the hysteroscopic morcellation group (median 9.5 min [range: 7.6-12.2] vs 12.2 min [range: 8.8-16.0]; p = .072). Perforation occurred at dilation or hysteroscope (re)introduction in 3 patients of the resectoscopy group, resulting in procedure discontinuation or prolongation of hospital stay. Perforation occurred at dilation in 1 patient in the hysteroscopic morcellation group; however, the procedure was successfully completed. Postoperatively, 2 patients of the hysteroscopic morcellation group were diagnosed with a urinary tract infection. Tissue was available for pathology analysis in all patients, except for 2 patients in the resectoscopy group in whom the procedure was discontinued due to perforation. CONCLUSION Hysteroscopic morcellation is a fast, effective, and safe alternative to bipolar resectoscopy for removal of endometrial polyps.

Uterine peristalsis and fertility: current knowledge and future perspectives: a review and meta-analysis

Although uterine contractions in the non-pregnant uterus have been studied extensively, the knowledge gained has not been used in general fertility treatment work-up. In this review paper, we provide an overview of the current knowledge on uterine peristalsis (UP), based on the available literature. This literature shows that UP influences pregnancy chances in both natural and artificial cycles. Although the physiological background of these contractions is not completely clear, we know that several factors can be of influence, like uterine pathologies and hormones. Several options to alter pregnancy outcome by interfering with uterine contractions have been studied. Our meta-analysis on therapeutic options shows positive results of progesterone at time of embryo transfer in IVF cycles or prostaglandins at time of intrauterine insemination, although the quality of evidence is low. These therapies are probably most beneficial in selected groups of patients with abnormal contraction patterns. The introduction of an objective and user-friendly UP measuring tool suitable for use in daily practice would make it possible to identify and monitor these patients. We suggest that future research should focus on the physiology of initiation of UP and on the development of an effective standard measuring tool.

Analysis of uterine activity in nonpregnant women by electrohysterography: A feasibility study

With an overall effectiveness below 30%, in vitro fertilization (IVF) is in urgent need for improvements, especially in view of the increasing trend in postponing childbirth in developed societies. Abnormal contraction of the uterus may underlie impaired fertility and unsuccessful IVF. However, currently, there is no method for quantitative assessment of uterine activity and guidance of dedicated intervention. Analysis of the electrohysterogram (EHG) has been extensively used in pregnancy for quantifying uterine contractions. In this paper, we evaluate, for the first time, the use of EHG analysis for characterizing contractions in women in two different phases of the menstrual cycle, when the uterus is expected to be active and quiescent. In this preliminary study, by estimating the time evolution of the EHG signal energy, we derive the contraction frequency, fC, as a possible marker for quantifying the activity of the uterus and discriminate between active and quiescent status. Ultrasound (US) image sequences are simultaneously recorded and visually analyzed for a qualitative validation of the results. The high correlation (0.91) between fC obtained by EHG and US analysis and the measured different values of fC in the two phases motivate further research to confirm the value of EHG analysis for contraction quantification in nonpregnant women.

OC22.04: Ultrasound-based strain mapping for contraction frequency in the non-pregnant uterus

Methods: A retrospective cohort study of women who underwent a laparoscopic myomectomy at University College London Hospital between December 2014 and November 2017 was carried out. Ultrasound images and operation notes were reviewed. The size and minimum distance of the fibroid from the endometrial cavity in a 2-dimensional longitudinal plane were determined from ultrasound images (negative distance was scored when the fibroid protruded into the cavity). Endometrial cavity breaches at the time of surgery were identified from the operation notes. Women who did not have a preoperative ultrasound and those who had more than two fibroids removed were excluded. Results: 74 women who had laparoscopic myomectomy and a preoperative ultrasound were identified. The median age was 36.0 (IQR 33 – 39.8) and the median fibroid diameter was 68.2mm (IQR 47.7 – 80.6). 10/74 (13.5%, 95% CI 5.7 – 21.3) had a breach of the endometrial cavity. Women who suffered a breach had a fibroid that was close to or within the endometrial cavity (distance from cavity -9.9 vs. 8.9mm, p=0.001, degree of protrusion 17% vs. 0.0% and intracavitary surface area 1463mm2 vs. 0.0). A logistic regression model with cavity breach as independent variable and ultrasonic variables as predictors selected minimum distance from cavity as the best predictor of cavity breach (OR 0.79, 95% CI 0.73 – 0.92). 10/19 (52.6%, 95% CI 30.2 – 15.1) of women with a submucosal component to their fibroid did not have a cavity breach. No women with a fibroid further than 5.2mm from the cavity had a breach identified at surgery. Conclusions: Identifying patients who are at increased risk of endometrial cavity breach based on ultrasound facilitates appropriate preoperative counselling regarding the risk of intrauterine adhesions and the need for Caesarean section.

Hysteroscopy in the Netherlands and Flanders : a survey amongst practicing gynaecologists

OBJECTIVE To gain insight in the current ideas on, and implementation of hysteroscopy amongst practicing gynaecologists in the Netherlands and Flanders. STUDY DESIGN In August 2016 an electronic questionnaire was sent to practising gynaecologist members of the Dutch (N = 591) and Flemish (N = 586) Society of Obstetrics and Gynaecology. RESULTS The response rate for the Netherlands was 15.4% (91/591), and for Flanders 27.0% (158/586). Responding gynaecologists have a preference for hysteroscopy for diagnosing and treating most intrauterine pathology. Flemish respondents are more hesitant in opting for hysteroscopy instead of curettage for treatment of polyps and placental remnants. There appears to be a wide diffusion of diagnostic and basic operative hysteroscopy. In contrast to Flanders, responding hysteroscopists from the Netherlands more often perform office hysteroscopic procedures. Hysteroscopic procedures, and office procedures in particular, are now educated during residency. Therefore, recently graduated gynaecologists have a preference for this technique. CONCLUSION Our survey confirms that nowadays the focus of treating intrauterine pathology is on less invasive techniques and preserving the uterus. Dutch responding hysteroscopists have more expertise concerning office hysteroscopy than their Flemish colleagues. Future research on the cost-effectiveness of and optimisation of patient comfort during office hysteroscopy is needed to support its further implementation.