The Role of Hysteroscopy in the Assessment of Fallopian Tubal Patency: A Comprehensive Review and Meta-analysis.

Hysteroscopy has been recognized as a reliable method for the evaluation of female infertility for several years. The outpatient setting is particularly convenient, as patients do not require general anesthesia and do not have to stay overnight. In recent years, more and more articles have dealt with the role of diagnostic hysteroscopy in tubal evaluation. Twenty-four articles were included in this comprehensive review and 14 of them were also included in a meta-analysis. This review provides an overview of the different techniques of hysteroscopic tubal evaluation, with a focus on perioperative changes in cul-de-sac volume, the air bubble technique ("Parryscope" technique), the Flow technique and selective hysteroscopic pertubation with methylene blue dye (SHPMBD). In pooled analyses, SHPMBD achieved the highest sensitivity for tubal patency (91.7%, 95% confidence interval, CI: 88.8-94.0), whereas the air bubble technique revealed the highest specificity of all methods (98.4, 95% CI: 95.3-99.6). Furthermore, in a meta-analysis of all methods on the assessment of single tubes, an overall sensitivity of 87.1% and an overall specificity of 79.8% (95% CI: 76.4-82.9) could be shown. In conclusion, the techniques of hysteroscopic tubal evaluation are well-tolerated, clinically relevant, and reliable.

"RAIL BIOPSY" A novel and useful technique for hysteroscopic endometrial target biopsy.

OBJECTIVE: Endometrial biopsy (EB) is one of the most common gynecologic procedures. Office-based EB has replaced procedures involving general/loco-regional anesthesia and cervical dilatation, performed in the operating room[1,2,3]. The Grasp Biopsy seems to be the most appropriate EB technique for reproductive aged women[1,2,4]. Recently, the Visual D&C performed with hysteroscopic tissue removal devices has shown to be a valid alternative[5]. However, it is often difficult to obtain ad adequate specimen in peri/post-menopausal women with hypo/atrophic endometrium[2]. Our aim is to show a novel hysteroscopic EB technique called "Rail Biopsy" which requires widespread and cheap instruments. SETTING: Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero-Universitaria di Bologna" Bologna, Italy. PARTICIPANTS: women referred to our center for hysteroscopic endometrial biopsy. INTERVENTIONS: We performed the "Rail Biopsy" technique with a 5.0 mm Continuous Flow Operative Hysteroscope with a 30° Lens and a 5Fr operative channel. We identify the endometrial target area (ETA) and we create a first track cutting through the endometrium in a caudo-cranial direction using cold scissors. We repeat the procedure creating a second parallel track, thus completing our "rail" and isolating a wide ETA. Then, in caudo-cranial direction, we cut through the stromal layer beneath the ETA. With a 5Fr cold grasping forceps, we clench the cranial edge of the ETA and we remove it from the uterine cavity. A high-quality specimen, even in case of hypo/atrophic endometrium or focal sessile lesions, can be obtained with this technique. The crucial aspect of the "Rail Biopsy" indeed is cutting through the stromal tissue, while the endometrium is minimally touched, avoiding thermal damage deriving from electrosurgery. The instruments required are widespread and cheap. Moreover, this technique can be performed on any wall of the uterus, under vision and, in the majority of patients, in an office-setting without cervical dilatation or general/loco-regional anesthesia, making it an attractive alternative to hysteroscopy performed in the operating room setting. Further studies comparing "Rail Biopsy" to other EB techniques are needed. CONCLUSION: We showed a novel approach for hysteroscopic EB that may be particularly useful in patients with hypo/atrophic endometrium, easy to learn and with low costs.

Correlation between hysteroscopic features and specific microbial species in women with chronic endometritis.

Objective and rationale: Chronic endometritis (CE) has recently been associated with unexplained infertility and recurrent miscarriages. The current gold standard for CE detection is histopathological examination. However, office hysteroscopy and endometrial cultures are also significant, due to the possible link between CE and various microorganisms. Bacterial colonization of the endometrium has been associated with reduced success rates of in vitro fertilisation embryo transfer. Few studies have tried to correlate CE hysteroscopy findings with pathogenic microorganisms. This prospective cohort study sought to establish whether hysteroscopic diagnostic lesions correlate with specific microbial species. Methods: The study encompassed women undergoing diagnostic tests for a range of subfertility health issues. 189 women completed the standard office diagnostic hysteroscopy (DH). 181 had also endometrial samples taken for microbial culture investigation. Correlation analysis (χ2 and Fisher's exact test) between hysteroscopic findings suggestive of CE and endometrial cultures was carried out. Logistic regression models were also fitted to measure whether a positive endometrial culture could affect CE conditions. Results: A significant association of E. coli was observed between the hysteroscopically characterized CE + group with focal hyperplasia, when compared to the non-CE group. Logistic regression analysis revealed that women positive for E. coli were 4.423 times more likely to have focal endometrial hyperplasia. No other significant correlations were identified between DH and positive endometrial cultures. Conclusions: The presence of E. coli in the endometrium was significantly correlated with focal hyperplasia findings from hysteroscopy, emphasizing the importance of microbial cultures in the diagnosis and targeted treatment of CE in women with subfertility.

Clinical utility of office hysteroscopy following failed in vitro fertilization-embryo transfer: A retrospective cohort study.

OBJECTIVE: Despite its widespread use, in vitro fertilization (IVF) outcomes are challenged by implantation failure, largely due to factors such as embryo quality and endometrial receptivity. In this study, we investigated the clinical effect of office hysteroscopy (OH) on the subsequent frozen-thawed embryo transfer (FET) in infertile women who experienced a failed IVF-embryo transfer (IVF-ET) cycle. METHODS: We included 577 infertile women who underwent OH because of a history of failed ET between October 2019 and September 2021. During OH, visible endometrial polyps (EPs) were diagnosed and removed by curette or biopsy forceps; chronic endometritis (CE) was diagnosed by histopathology and immunohistochemistry and treated with oral doxycycline (0.2 g/d) for 14 days. According to the hysteroscopic findings and endometrial pathology with immunohistochemistry, patients were divided into three groups: group A (n = 161) had CE with or without EPs, group B (n = 156) had EPs only, and group C (n = 260) had no CE or EPs. RESULTS: In the following FET cycle, the implantation rates were 47%, 51%, and 45% (P = 0.411); the clinical pregnancy rates were 56%, 62%, and 55% (P = 0.436); the live birth rates were 45%, 51%, and 42% (P = 0.205); and the miscarriage rates were 18%, 16%, and 22% (P = 0.497) in groups A, B, and C, respectively. There were no significant differences among groups (P > 0.05). CONCLUSION: OH is helpful for diagnosis and treatment of abnormal intrauterine environment in women with a failed IVF cycle and further improves their pregnancy outcome in the following FET.

Effectiveness of Manual Hysteroscopic Tissue Removal Device for Intrauterine Polyps in Infertile Women in Both Operating and Office Settings.

Background: Mechanical hysteroscopic tissue removal (mHTR) systems are widely used for removing intrauterine pathology. Given the startup and procedural costs for electrically powered mechanical units, disposable manual mHTR systems have been developed. Methods: With little published, we describe its effectiveness for hysteroscopic intrauterine polypectomy. Results: One-hundred fifty-seven infertile women underwent hysteroscopic polypectomy with the manual mHTR device. Complete removal was accomplished in all but three cases, with blood loss being <10 mL and all specimens deemed sufficient for histopathologic diagnosis. Conclusions: These results suggest that the disposable manual mHTR system is effective in removing endometrial polyps. Head-to-head comparisons with other alternative technologies are needed.

Outpatient hysteroscopy impact on subsequent assisted reproductive technology: a systematic review and meta-analysis in patients with normal transvaginal sonography or hysterosalpingography images.

BACKGROUND: Standard management for intrauterine lesions typically involves initial imaging followed by operative hysteroscopy for suspicious findings. However, the efficacy of routine outpatient hysteroscopy in women undergoing assisted reproductive technology (ART) remains uncertain due to a lack of decisive high-quality evidence. This study aimed to determine whether outpatient hysteroscopy is beneficial for infertile women who have unremarkable imaging results prior to undergoing ART. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines, incorporating data up to May 31, 2023, from databases such as PubMed, Embase, and the Cochrane Library. The primary outcome assessed was the live birth rate, with secondary outcomes including chemical pregnancy, clinical pregnancy rates, and miscarriage rates. Statistical analysis involved calculating risk ratios with 95% confidence intervals and assessing heterogeneity with the I2 statistic. RESULTS: The analysis included ten randomized control trials. Receiving outpatient hysteroscopy before undergoing ART was associated with increased live birth (RR 1.22, 95% CI 1.03-1.45, I2 61%) and clinical pregnancy rate (RR 1.27 95% CI 1.10-1.47, I2 53%). Miscarriage rates did not differ significantly (RR 1.25, CI 0.90-1.76, I2 50%). Subgroup analyses did not show a significant difference in clinical pregnancy rates when comparing normal versus abnormal hysteroscopic findings (RR 1.01, CI 0.78-1.32, I2 38%). We analyzed data using both intention-to-treat and per-protocol approaches, and our findings were consistent across both analytical methods. CONCLUSIONS: Office hysteroscopy may enhance live birth and clinical pregnancy rates in infertile women undergoing ART, even when previous imaging studies show no apparent intrauterine lesions. Treating lesions not detected by imaging may improve ART outcomes. The most commonly missed lesions are endometrial polyps, submucosal fibroids and endometritis, which are all known to affect ART success rates. The findings suggested that hysteroscopy, given its diagnostic accuracy and patient tolerability, should be considered in the management of infertility. DATABASE REGISTRATION: The study was registered in the International Prospective Register of Systemic Review database (CRD42023476403).

Barriers to Office Hysteroscopy in Fellowship Education and Practice.

STUDY OBJECTIVE: To identify the top 3 perceived barriers to performing office hysteroscopy (OH) by minimally invasive gynecologic surgery (MIGS) faculty and fellows and identify opportunities for education on this key topic that will be most effective in fellowship training and MIGS practice. DESIGN: Cross-sectional survey study targeted at all American Association of Gynecologic Laparoscopists-accredited Fellowship in Minimally Invasive Gynecologic Surgery fellows, program directors, and associate program directors in February to April 2022. The survey was designed by faculty who have extensive experience in OH procedures. In addition, a literature search was performed to aid with question design. SETTING, PATIENTS, AND INTERVENTIONS: This was a REDCap electronic survey administered through the Fellowship in Minimally Invasive Gynecologic Surgery listserv. No additional follow-up was performed after survey completion. The 15-minute survey was sent to 60 program directors, 92 assistant program directors, and 158 fellows, including the incoming class of 2024 and the 2022 fellowship graduates. MEASUREMENTS AND MAIN RESULTS: A total of 93 responses were received; 67% of respondents performed OH but 73% of those performed 5 procedures or less per month. Most participants controlled pain with nonsteroidal anti-inflammatory drugs +/- paracervical block. The most common perceived barrier to performing OH was concern over pain management. Other commonly cited concerns were equipment costs, sterilization costs, and office staff training; 37% to 44% of respondents also cited lack of departmental support and insufficient clinic time, respectively, as barriers, and 56% indicated they are interested in educational materials on OH. CONCLUSION: Our study suggests general interest in, but a low volume of, OH among MIGS fellows and faculty. The most common perceived barrier was concern regarding pain management. This has been well studied in the literature and likely presents an area for greater education to improve OH utilization. We also uncovered concerns regarding systemic barriers, such as equipment costs, departmental support, and clinic structure. This is an area for further research and advocacy efforts to address barriers to OH on a system level.

Office hysteroscopy to guide intrauterine device hook use for the removal of a deeply embedded intrauterine device.

Office hysteroscopy is a common examination method in gynecological clinics. In most cases, it can only be examined but not treated. Here, we present our specific technique used office hysteroscope to guide intrauterine device (IUD) hook in the removal of deeply embedded IUD which provided direct visualization and sufficient force.

Pain and anxiety management with virtual reality for office hysteroscopy: systemic review and meta-analysis.

PURPOSE: Office hysteroscopy (OH) is a commonly performed procedure, although it might be associated with some degree of pain and anxiety. Our aim was to determine the effects of virtual reality on pain and anxiety levels felt by patients undergoing OH. METHODS: MEDLINE, Embase, Google Scholar, Cochrane Library, clinicaltrials.gov, ProQuest, Grey literature, and manual searching of references within studies found in the initial search were systematically searched using the terms 'Virtual Reality' and 'Hysteroscopy' without time or language limitations. The review considered all studies assessing the impact of virtual reality (VR) over OH outcomes, and prospective randomized trials were included in the meta-analysis. Retrospective and case - control studies were excluded from the meta-analysis. RESULTS: We identified 17 studies, of which four randomized controlled studies were included in the meta-analysis (327 participants, 168 in the VR group and 159 in the control group). On a 0-10 scale, pain sensation and maximal pain sensation during the operation were not statistically different between study and control groups (relative risk (RR) = -0.64, 95% C.I (-1.57)0.29) and (RR = -0.93, 95% C.I (-3.33) - 1.47), respectively. Anxiety measurement was statistically lower in the study group (RR = -1.73, 95% C.I (-2.79) - ( -0.67)). CONCLUSIONS: The available data suggest that VR techniques do not decrease the pain sensation during OH however, they do contribute to a reduction in the anxiety levels experienced by patients. PROSPERO registration number CRD42023432819.

Does vaginal cleansing with iodine decreases infection rate in office hysteroscopy?

PURPOSE: To determine whether preoperative vaginal cleansing with iodine-based solution prior to hysteroscopy, reduces postoperative infection rate compared to no vaginal cleansing. METHODS: A retrospective study at a single tertiary, university affiliated hospital of all individuals who have had an office hysteroscopy. Study group consisted of patients who have had preoperative vaginal cleansing with iodine-based solution and were compared to those who have not. Any procedural related complaints at the 30 days following the hysteroscopy were recorded. RESULTS: A total of 505 were available for analysis, 183 in the study group and 322 in the control group. The most common indications for operation were infertility evaluation (33.9% vs. 28.6%) and retained products of conception (33.3% vs. 29.2%), and most common procedures were diagnostic only (49.7% vs. 42.5%) followed by adhesiolysis (12% vs. 14.3%). No statistical differences were noted with regards to postoperative infections, as only one case of pelvic inflammatory disease was noted, in the iodine cleansing group (0.19% for postoperative infection). CONCLUSION: Our comparative study may suggest that the use of preoperative iodine solution prior to office hysteroscopy does not decrease the postoperative infection rate up to 30 days, thus can be avoided.

Diode laser use in hysteroscopic surgery: current status and future perspectives.

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

The effect of informing the patient about the procedure with video imaging before office hysteroscopy on pain.

OBJECTIVE: To evaluate the effect of informing patients undergoing diagnostic office hysteroscopy via a video 24 h before the procedure and determine the changes in pain scores, channel transit time, the degree of difficulty of the procedure, and physiological parameters. DESIGN: Single-blind randomized controlled trial. SETTING: The study was conducted between September 1, 2021 and April 1, 2022 at the University of Health Sciences Bakirkoy Dr. Sadi Konuk Training and Research Hospital. PARTICIPANTS: A total of 134 patients aged 18-65 years who needed diagnostic office hysteroscopy. INTERVENTIONS: Participants were randomized into two groups, the standard information group (Group 1: controls), and the video information + standard information group (Group 2). After office hysteroscopy, a visual analog scale (VAS) and Likert scale were used to assess pain and the degree of difficulty of the procedure, respectively. Physiological parameters were evaluated before and after the procedure. MAIN OUTCOME MEASURE: To determine the effect of video-based multimedia information administered 24 h before office hysteroscopy on post-procedure pain. RESULTS: The mean VAS score of the group that watched the training video (3.02 ± 1.88) was significantly lower than the control group (4.72 ± 2.54) who did not watch the training video (p < 0.001). The mean cervical channel transit time in seconds (sec) during the procedure was found to be significantly higher in the control group (21.57 ± 15.10 s) than in the video-watching group (p = 0.011). There was no significant difference between the groups in terms of physiological parameters and the degree of ease of the procedure. CONCLUSION: Our study has shown that informing patients in a pre-procedure video is an effective approach that shortens the duration of the channel transit time and reduces pain.

Nonsteroidal anti-inflammatory drug with a local anesthetic compared to nonsteroidal anti-inflammatory drug alone significantly reduce the pain associated with vaginoscopic office hysteroscopy.

INTRODUCTION AND OBJECTIVES: Pain is the most common cause of office hysteroscopy (OH) failure. There is no consensus on alleviation of pain during OH. The aim was to compare the effectiveness of pain-relieving methods during OH. STUDY DESIGN: A prospective randomized open-label trial included women subjected to OH. All women received 100 mg of ketoprofen intravenously pre-procedure. Women were randomly assigned to 3 arms: A) no local anesthesia, B) infiltration anesthesia with 20 ml of 1% lidocaine solution, C) paracervical block with 20 ml of 1% lidocaine solution. Karl Storz Bettocchi® rigid hysteroscope with a 5 mm operative sheath was used. Intensity of pain in numeric rating scale (NRS), intensity of cervical bleeding, frequency of vasovagal episodes, and failure rate were compared. RESULTS: The study involved 201 women, 67 in each arm. NRS value during OH was higher in arm A than in B and C (6.3 vs. 5.1 vs. 5.0; p = 0.01). NRS value after OH did not differ and in all arms pain was imperceptible (p = 0.007). Cervical bleeding was more frequent in arm B than in A and C (76.1% vs. 33.4% vs. 35.9%; p < 0.0001), but its intensity did not differ from the other arms (p = 0.3). Vasovagal episode was most common in arm B (p = 0.048). There was no difference in the failure rate between the arms (p = 0.08). CONCLUSIONS: The paracervical block, albeit technically the most laborious, has proven to be the most beneficial for the patient in terms of overall comfort and for the surgeon regarding feasibility.

Gynecology Resident Experience with Office Hysteroscopy Training.

Background: Hysteroscopy is the gold standard for evaluating intrauterine pathology. The majority of physicians currently perform hysteroscopy in the operating room. Lack of training has been cited as a barrier to performing office hysteroscopy; however, resident training in office hysteroscopy has not yet been evaluated. Methods: A prospective cross-sectional survey was performed. A validated 17 question survey tool was sent to 297 program directors of Accreditation Council for Graduate Medical Education accredited obstetrics and gynecology residency programs for distribution to their residents. The survey utilized a Likert scale to assess resident interest in learning office hysteroscopy, satisfaction in training, and perceived self-efficacy to perform office hysteroscopy independently upon graduation. Results: Two hundred and ninety-three obstetrics and gynecology residents responded. Of the respondents, 26.3% reported receiving training in office hysteroscopy. There was no statistically significant difference in training among postgraduate years or program regions. A greater proportion of male residents received training when compared to female residents (42.9% vs. 24.2%, p = 0.019). Ninety-four percent of residents reported interest in learning office hysteroscopy. Satisfaction with hysteroscopy training in the operating room versus the office was 91.1% vs. 11.3% respectively. Of the fourth-year residents, 17.4% felt they could perform office hysteroscopy independently upon graduation and 14.5% reported feeling comfortable performing the procedure. Conclusions: Residency training in office hysteroscopy is lacking and residents are unprepared to perform the procedure after graduation. Enhanced residency training in office hysteroscopy would likely improve resident comfort and ability to perform office hysteroscopy in practice.

Clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for the resection of endometrial polyps in an office setting.

PURPOSE: A first clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for office polypectomy without any anesthesia. METHODS: Women with at least one small endometrial polyp were eligible. Hysteroscopic polypectomy was performed using the Resectr™ 5fr in an office setting, without any anesthesia. RESULTS: One hundred and two hysteroscopic polypectomies were included in the analysis. The median installation time was 1.9 min (95% confidence interval (CI) 1.6-2.1). The median time to complete polyp removal was 1.2 min (95% CI 0.8-1.6). The median surgeon's safety, practical, and comfort scores on a 5-point Likert scale were high (5 (5-5), 5 (4-5), and 5 (4-5), respectively). Women's pain score was low (median 1 (0-3)), whereas the satisfaction rate was high (median 5 (5-5)), both on a 5-point Likert scale. There were two conversions (hysteroscopic scissors (n = 1), a new Resectr™ 5fr device (n = 1)). There was one incomplete procedure (tissue hardness). CONCLUSION: Hysteroscopic removal of small polyps, using the [Formula: see text] 5fr in an office setting is feasible in terms of installation and resection time. Surgeon's practical, comfort, and safety scores are high, whereas women report low pain scores and high satisfaction rates.  TRIAL REGISTRATION: Dutch Clinical Trial Registry (NTR 7119, NL6923): https://www.trialregister.nl/trial/6923 . Date of registration: 27/03/2018.

Efficacy of Oral Nifedipine, Naproxen, or Placebo for Pain Relief During Diagnostic Hysteroscopy in an Office Setting: A Randomized Pilot Study.

STUDY OBJECTIVE: To compare nifedipine, naproxen, or placebo for pain relief during diagnostic hysteroscopy. DESIGN: Double-blind, randomized controlled pilot study. SETTING: University hospital. PATIENTS: Women scheduled for office diagnostic hysteroscopy (n = 60). INTERVENTIONS: Women received nifedipine (2 tablets of 10 mg), naproxen (2 tablets of 250 mg), or placebo (2 tablets of 500 mg lactose) 30 to 60 minutes prior to hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Sixty patients were enrolled in the study (21 in the nifedipine group, 19 in the naproxen group, and 20 in the placebo group). The median pain scores during hysteroscope insertion, measured on a Visual Analog Scale (VAS), were 1 (interquartile range (IQR) 0-0), 2 (0-4) and 1 (0-1) in the nifedipine, naproxen and placebo group, respectively (P,14). The median VAS scores during hysteroscopy were 5 (IQR 2-7), 5 (4-8) and 5 (3-7) in the nifedipine, naproxen and placebo group, respectively (P,73). The median VAS scores immediately after hysteroscopy were 2 (IQR 0-4), 3 (0-6) and 3 (1-5) in the nifedipine, naproxen and placebo group, respectively (P,40). The median VAS scores 30 minutes after hysteroscopy were 1 (IQR 0-2), 1 (0-1) and 1 (0-2) in the nifedipine, naproxen and placebo group, respectively (P,63). Hysteroscope insertion failed in 1 case (naproxen group) because of cervica`l stenosis (P,32). Flushes, fatigue and vertigo, 30 minutes after the procedure, were significantly more prevalent in the nifedipine group compared to the naproxen (p < .001, p,03, p,03, respectively) and the placebo group (p < .001, p,01, p,01, respectively). Palpitations occurred only in the nifedipine group (p < .001). The day after the procedure, the headache was most prevalent in the nifedipine group compared to the naproxen group (p,001) and the placebo group (p,001). CONCLUSION: In our pilot study, pain relief and success rates for office diagnostic hysteroscopy were not significantly different between nifedipine, naproxen, and placebo. Nifedipine was associated with more, albeit tolerable, side-effects.

Restoring Fertility of Patients with Severe Asherman's Syndrome in the Office Setting: A Step-by-Step Recipe for Success.

OBJECTIVE: To describe an effective in-office hysteroscopic strategy to restore fertility of patients with severe Asherman's syndrome. DESIGN: A step-by-step video demonstration of the technique with an emphasis on the key portions of the procedure. A detailed narrated description of the steps is provided. SETTING: Tertiary care University Hospital. INTERVENTIONS: Three patients were managed by hysteroscopy performed in the office setting without anesthesia. Case 1 is a 34-year-old woman with obstetrical history of first-trimester incomplete abortion treated with Dilation and Curettage (D&C), followed by a tubal ectopic pregnancy treated with laparoscopic partial salpingectomy and a subsequent pregnancy on the tubal stump treated with uterine artery embolization. Case 2 is a 40-year-old woman with history of tubal ectopic pregnancy treated with salpingectomy, a surgical first-trimester voluntary termination of pregnancy with D&C and a full term vaginal delivery complicated with retained products of conception that were removed with D&C. Case 3 is a 35-year-old woman with two previous first-trimester spontaneous miscarriages both treated with D&C. Case 1 and 3 were treated using miniaturized mechanical instruments only; in case 2, miniaturized mechanical instruments and the 15 Fr bipolar mini-resectoscope were used. Preoperative 2D and 3D ultrasound were used to predict the complexity of the cases and to guide the surgeon during the procedure. Intrauterine lysis of adhesions was concluded when both tubal ostia were visualized, and the uterine cavity was determined to have adequate shape and volume. At the end of the procedures, hyaluronic acid-based gel was applied to prevent new intrauterine adhesion formation. Two weeks after the initial procedure, a second look diagnostic hysteroscopy was performed. Only one patient (#1) needed additional lysis of adhesions; in this case, at the end of the procedure, a Word catheter was inserted as a barrier method for the prevention of adhesion formation. Eight weeks later, the word catheter was removed, and additional lysis of adhesions was performed. All the surgical procedures were performed without complication, and a healthy endometrium was observed at the second look hysteroscopy, in all the three patients. All 3 patients conceived after the procedure. Pregnancy was achieved after one IVF cycle with the transfer of one frozen embryo in case 1 and spontaneously in cases 2 and 3. Patient 1 was delivered by elective caesarean section due to placenta previa, while the other two patients had normal vaginal deliveries. Patient 1 had Retained Products of Conception requiring hysteroscopic removal using a 27 Fr Resectoscope. CONCLUSION: When using innovative miniaturized instruments and adequate surgical technique, hysteroscopic lysis of adhesions is a feasible and effective in-office strategy to restore fertility in patients with severe Asherman's syndrome. The use of 2D and 3D ultrasound played an important role in the preoperative workup of the patient with Asherman's syndrome.

Predictive Factors of Tolerance in Office Hysteroscopy - a 3-Year Analysis from a Tertiary Center

Abstract Objective Pain is the primary limitation to performing hysteroscopy. We aimed to evaluate the predictive factors of low tolerance to office hysteroscopic procedures. Methods Retrospective cohort study of the patients who underwent office hysteroscopy from January 2018 to December 2020 at a tertiary care center. Pain tolerance to office-based hysteroscopy was subjectively assessed by the operator as terrible, poor, moderate, good, or excellent. Categorical variables were compared with the use of the Chi-squared test; an independent-samples t-test was conducted to compare continuous variables. Logistic regression was performed to determine the main factors associated with low procedure tolerance. Results A total of 1,418 office hysteroscopies were performed. The mean age of the patients was 53 ± 13.8 years; 50.8% of women were menopausal, 17.8% were nulliparous, and 68.7% had a previous vaginal delivery. A total of 42.6% of women were submitted to an operative hysteroscopy. Tolerance was categorized as terrible or poor in 14.9% of hysteroscopies and moderate, good, or excellent in 85.1%. A terrible or poor tolerance was more frequently reported in menopausal women (18.1% vs. 11.7% in premenopausal women, p = 0.001) and women with no previous vaginal delivery (18.8% vs. 12.9% in women with at least one vaginal birth, p = 0.007). Low tolerance led more often to scheduling a second hysteroscopic procedure under anesthesia (56.4% vs. 17.5% in reasonable-to-excellent tolerance, p < 0.0005). Conclusion Office hysteroscopy was a well-tolerated procedure in our experience, but menopause and lack of previous vaginal delivery were associated with low tolerance. These patients are more likely to benefit from pain relief measures during office hysteroscopy.

Vasovagal Syncope during Office Hysteroscopy-A Frequently Overlooked Unpleasant Complication.

Due to technological advancements in miniaturization of instruments and improved optics, the number of office hysteroscopic procedures has increased over time. Office hysteroscopy is preferred due to avoidance of general anesthesia and decreased overall cost. Vasovagal syncope has been implied as the most common complication. Vasovagal syncope is associated with inappropriate reflex vasodilation and bradycardia in the setting of an acute malfunction between the autonomic nervous system and the cardiovascular system; however, there is no mortality associated with vasovagal syncope. A management strategy for acute vasovagal reflex during office hysteroscopy is proposed in order to manage this common complication.

Accuracy of office hysteroscopy in diagnosis of endometrial pathologies compared to ultrasound and histopathology in Baghdad Teaching Hospital.

BACKGROUND: Menstrual problems with all manifestations ranging from life-threatening bleeding to amenorrhea are considered patterns of abnormal uterine bleeding (AUB), which is until now a popular reason for referral to the gynaecologic clinic and requires a special diagnostic tool. OBJECTIVE: To assess the accuracy of hysteroscopy in diagnosing endometrial pathologies and to compare it with sonographic and histopathologic reports. PATIENTS AND METHODS: A prospective study conducted in the Baghdad Teaching Hospital on 60 Iraqi females having varying complaints from abnormal uterine bleeding in pre- and post-menopausal women, infertility, and chronic pelvic pain with normal or abnormal ultrasound findings. Office hysteroscopy was done and an endometrial biopsy was obtained for histopathology for a period of 10 months between September 2020 and June 2021. RESULTS: The current study showed that hysteroscopy was more accurate in diagnosing sensitivity of endometrial poly (100%), fibroids (83%), hyperplasia (84.2%), and cancer (50%) whereas ultrasounds were more accurate in diagnosing sensitivity to endometrial myoma (90%). Hysteroscopy and ultrasound showed low sensitivity in detecting endometrial cancer (50% and 34%, respectively). CONCLUSION: Although a transvaginal ultrasound was considered an integral part in the diagnosis of endometrial pathologies, it can be used for initial investigation, however, when suspecting endometrial pathology, hysteroscopy can be more advanced for evaluation, immediate treatment of endometrial masses, and obtaining targeted biopsies. Hysteroscopy showed high sensitivity in detecting endometrial polyps.