Office hysteroscopy.

Diagnostic, panoramic hysteroscopy can be performed in an office setting with small discomfort to the patient. The procedure enables the physician to search for organic intrauterine abnormalities and to select the proper form of therapy based on the observations. Often no pathology is seen and further surgical interventions are not needed. This operation currently represents the state of the art for investigation of the endometrial cavity. In the future it will become the standard of care as the first step for evaluation of causes of abnormal uterine bleeding in selected patients.

Adenomyosis.

The clinical diagnosis of adenomyosis is elusive but should be suspected in women who complain of abnormal uterine bleeding or dysmenorrhea and have a regular but enlarged uterus. The use of newer diagnostic imaging modalities and recent research on myometrial biopsies should enable the clinician to arrive at a definite preoperative diagnosis and offer the patient treatment tailored to her needs.

Therapeutic hysteroscopic procedures.

Hysteroscopy has evolved from a diagnostic procedure into a therapeutic method for a variety of conditions. Instruments specifically designed for hysteroscopic operative procedures have improved. The indications for therapeutic hysteroscopy are increasing and its proper applications can improve patient's gynecologic care. These facts should stimulate the gynecologist to become proficient with hysteroscopy for diagnosis and the treatment of many intrauterine abnormalities. In selected patients there are major advantages including the avoidance of a laparotomy with the potential sequelae that can follow operations requiring entrance into the peritoneal cavity. The operative techniques have been refined and, with experience, good postoperative results and low morbidity have become evident. The septate uterus can be treated by hysteroscopic metroplasty with improved reproductive outcome. Symptomatic submucous myomas in selected patients can be removed hysteroscopically. Lysis of intrauterine adhesions has become the standard method of therapy. Foreign bodies lost in the uterine cavity or embedded IUDs can be removed atraumatically under direct vision. As the approach to intrauterine problems is refined, other applications are being investigated such as tubal cannulation, endoscopic chorionic villus sampling, and application of hysteroscopy to new reproductive technologies such as the placement of gametes in the fallopian tubes. Because of the simplicity of approaching the uterotubal ostia transcervically, hysteroscopy remains in the front line of investigation as a possible approach for inducing tubal occlusion as a permanent or temporary method of contraception. Finally, laser energy is being used in patients with intractable uterine bleeding to photocoagulate the endometrium and to create amenorrhea by means of inducing severe intrauterine adhesions.

Gynecologic endoscopy in infertility.

Pelvic endoscopic techniques enable the physician to make accurate diagnoses, to treat specific pelvic disorders, and to gather information for research. This article focuses on these techniques as they apply to the management of infertile patients. Included for discussion are diagnostic and therapeutic laparoscopy and hysteroscopy, culdoscopy, and salpingoscopy.

Therapeutic hysteroscopy.

It is the responsibility of physicians in gatherings such as ours to set the tone and speak forthrightly about accomplishments and limitations. The fundamentals of diagnostic hysteroscopy are well known and now is the time for us to push forward to ascertain whether this endoscopic approach, in selected patients, is more innocuous than the conventional laparotomy. I have tried to indicate the clinician's dilemma in the search for the proper approach to several types of uterine abnormalities. As enthusiastic hysteroscopists, we must continue to analyze and document our findings, with careful concern so as to avoid poorly substantiated claims.

PIP: Some of the problems of therapeutic hysteroscopy are addressed with focus on methods and interpretations of results. At this time, intrauterine adhesions seem to be the best indication for therapeutic hysteroscopy. When one reviews the many reports on this topic, it becomes evident that results are difficult to compare due to a lack of classification of intrauterine adhesions. There seems to be no standard operative technique for their removal. Preoperative regimens differ, and the contemporary use of an IUD seems paradoxical. The restoration of menses in a patient who previously has had amenorrhea or hypomenorrhea is considered favorable, but reports of the percentage of pregnant patients postoperatively can be misleading in women whose problem was mostly repeated abortion. The end result of an uncomplicated term pregnancy should be regarded as the ultimate measure of success. Most likely the initial indication for therapeutic hysteroscopy was for the removal of the occult intrauterine IUD. Presently, the hysteroscope is infrequently used for this purpose. A uterine sound can be introduced to feel for the device, and in most instances the IUD can be removed easily with a uterine packing forceps. The findings on the hysterogram give the initial clue to the discovery of a congenital uterine abnormality, but the radiographic findings cannot predict which patients will be amenable to hysteroscopic metroplasty. The final decision depends upon both the laparoscopic and hysteroscopic results. The hysteroscopic procedure offers the patient a shorter hospitalization, a lower rate of complications, avoids postoperative intraabdominal adhesions, and, if successful, obviates the need for a later cesarean delivery. Amin and Neuwirth published results of hysteroscopic myomectomy performed on 32 patients. 75% of these patients experienced no recurrent abnormal bleeding during a followup of 4 years. Submucous myomas have been resected, morcellated, and removed during therapeutic hysteroscopy under laparoscopic control. Several authors have reported cannulating tubes, but this author is unaware of successful pregnancies from previous tubal cannulation of proximally obstructed tubes. The possibility of sterilization qualifies as a therapeutic use of the hysteroscope, but it would require an entire symposium to cover the subject adequately. To date, hysteroscopic sterilization techniques still must be considered experimental.

Reversibility of female sterilization.

PIP: The discussion considers the current status of reversibility of sterilization in the US and describes clinical and experimental efforts for developing techniques designed for reversibility. It focuses on regret following sterilization, reversal potential of current sterilization techniques, patient selection, current reversal techniques, results of sterilization procedures, experimental approaches to reversal of current techniques of sterilization, and sterilization procedures devised for reversibility, in humans and in animals. Request is the 1st stage of reversal, but a request for sterilization reversal (SR) does not always mean regret for a decision made at the time. Frequently it is a wish to restore fertility because life circumstances have changed after a sterilization that was ppropriate at the time it was performed. Schwyhart and Kutner reviewed 22 studies published between 1949-69 in which they found that the percentage of patients regretting the procedure ranged from 1.3-15%. Requests for reversal remain low in most countries, but if sterilization becomes a more popular method of contraception, requests will also increase. The ideal operation considered as a reversaible method of sterilization should include an easy, reliable outpatient method of tubal occlusion with miniml risk or patient discomfort that subsequently could be reversed without the need for a major surgical intervention. Endoscopic methods have progressed toward the 1st objective. A recent search of the literature uncovered few series of SR of more than 50 cases. The 767 operations found were analyzed with regard to pregnancy outcome. The precent of live births varied from 74-78.8%, and the occurance of tubal pregnancies ranged from 1.7-6.5%. All of the confounding variables in patient selection and small numbers of reported procedures preclude any conclusion about the different techniques or the number of operations that give a surgeon a level of expertise. Few authors classify their results of SR according to the original sterilization procedure. The most commonly performed sterilization (Pomeroy) was the most frequently reported to have undergone a reversal attempt, with a 50% success rate based on term or intrauterine pregnancies. Electrocoagulation was the next most frequent technique for reversal, with a 41% success rate. The less destrictive mechanical tehcniques, clip and band, had a reversal rate of 84% and 72%, respectively. A table summarizes sterilization procedures devised for reversibility in women. A women seeking sterilization should be advised that sterilization is permanent if no further tubal surgery is performed and that reversal is possible but involves a major and expensive operation.^ieng

The efficacy of postoperative hydrotubation: a randomized prospective multicenter clinical trial.

Term pregnancies following surgery on patients with distal tubal obstruction have been disappointingly few. There has been continuing interest in whether postoperative hydrotubation increases the rate of pregnancy following salpingoneostomy and fimbrioplasty. This hypothesis was tested in a prospective, randomized, multicenter clinical trial. Patients with no infertility factors other than distal fimbrial disease were randomly assigned to either a control group (no hydrotubation, n = 86) or one of two treatment groups (hydrotubation with lactated Ringer's solution, n = 60, or lactated Ringer's solution containing hydrocortisone, n = 60). The statistical evaluation of differences among treatment groups was based on the Cox Proportional Hazards Model, which allows for covariable adjustment and for the inclusion of all patients regardless of the length of follow-up. A significant difference in the live birth rate could not be demonstrated among the groups studied (P = 0.36). The probability of a successful live birth among women treated by hydrotubation with hydrocortisone was about one-half that of the other groups (P = 0.12). Patients with moderate and severe disease had a substantially lower probability of pregnancy than those with mild disease (P = 0.013 and P = 0.0016, respectively). The probability of pregnancy increased somewhat as the number of previous pregnancies increased (P = 0.12). In this clinical trial, a beneficial effect following postoperative hydrotubation could not be demonstrated.

Hysterosalpingography.

A brief review of the technique of hysterosalpingography is provided. It remains an important diagnostic study in searching for causes of infertility. HSG is a safe, simple procedure that enables the lumina of the uterine cavity and fallopian tubes to be outlined. Fundamentals in techniques have been stressed so as to limit the errors of omission and commission. During the course of many years, I have been honored by my colleagues, who have requested me to review interesting HSGs. Thus, I have been able to accumulate a series of x-rays that I can share with the readers of Modern Trends. Although these photographs seemed unique, many of them probably have been seen by other investigators. They are presented because of their important diagnostic features.

Panoramic CO2 hysteroscopy.

The method of CO2 panoramic hysteroscopy was described. It can be performed as an office procedure without the need for preliminary cervical dilatation or even a paracervical nerve block. The risks are minimal, and the benefits of being able to see the uterine cavity are manifold. Hysteroscopy is a relatively simple endoscopic procedure to learn, and its use in the diagnosis and management of abnormal uterine bleeding was emphasized.

Diagnosis and treatment of intrauterine adhesions by microhysteroscopy.

In this report of 69 patients, a new type of hysteroscope was used to evaluate the extent and character of intrauterine adhesions, to perform lysis of them, and to monitor the effects of therapy. Additionally, prospective studies with regard to pathogenesis and endometrial regeneration can be achieved in vivo. In 59 patients the procedures were performed in an office setting using a CO2 hysteroscopic technique without the need for local anesthesia or cervical dilatation. Of 30 infertile patients, 38% subsequently had uncomplicated deliveries. The severe forms of this disease still remain very difficult to treat effectively. When the adhesions were severe or the procedure painful, the operation was scheduled under general anesthesia (ten cases). A sequential hysteroscopy with good patient acceptance affords additional opportunity for removing residual adhesions and intrauterine devices, and serves as a basis for ending treatment with steroids.

Lysis of intrauterine adhesions under hysteroscopic control. A report of 25 operations.

Twenty-five women who had intrauterine adhesions were treated under hysteroscopic control and with ancillary medical therapy. Preoperatively, 18 patients complained of amenorrhea secondary to a curettage of a recently pregnant uterus. Following therapy described in this report, 11 of them subsequently conceived, 6 delivered at term, 2 had premature deliveries, and 3 other pregnancies ended in abortions. All patients resumed normal menses following treatment. A system for staging the severity of intrauterine adhesions is suggested so that results of therapeutic regimens can be compared.

The 100th anniversary of tubal sterilization.

PIP: Tubal sterilization is a relatively new operation within gynecology. The history of tubal sterilization since 1809 is traced through old medical texts. Certain details of the procedures being performed to effect tubal sterilization are reviewed. Although laparoscopic tubal sterilization seems to have been tried 1st in 1941, more than 1/4 of a century elapsed before it gained in popularity as a method of sterilization.^ieng

Prevention of postoperative adhesions in rabbits with ibuprofen, a nonsteroidal anti-inflammatory agent.

Twenty-six New Zealand White rabbits were randomly assigned to control or treated groups. In the treated group, the rabbits were medicated with either dexamethasone or ibuprofen. The injuries were made as standard as possible for each animal. The animals were killed 2 to 3 weeks postoperatively and the extent of adhesions was evaluated. Ibuprofen appeared to inhibit the formation of significant adhesions as compared with adhesion formation in untreated control animals, and the results seemed as effective as in the dexamethasone-treated animals. Further studies should be performed to substantiate these initial observations and to determine the most effective dosage. Ibuprofen may have a potential place in tubal surgery.

An analysis of macrosurgical and microsurgical techniques in the management of the tuboperitoneal factor in infertility.

One hundred and sixty tubal reconstructions were analyzed according to a classification which describes the type of tubal repair and the tubal segment treated. The results in 80 women who were operated upon just prior to the application of microsurgical principles were compared with those in 80 women in whom these techniques were employed. In expressing the results, no patients were excluded for any reason. Anatomical patency was not evaluated, and functional patency was measured by conception (abortion, tubal, or term pregnancy). Of the 80 women who had tuboplasty with conventional surgery, 10 (12.5%) successfully delivered at term, but 14 (17%) had tubal gestations. Almost 28% of the women (22) had successful pregnancies after microsurgery, but in 9 (11%) extrauterine pregnancies resulted. The three women with current intrauterine pregnancies could improve the microsurgical series to 31% successful pregnancies. Our initial experience with microsurgical techniques seems to show an increased number of term pregnancies, principally in patients who have undergone anastomosis.