Fertility after treatment of Asherman's syndrome stage 3 and 4.

STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopic adhesiolysis and subsequent fertility in patients with adhesions stage 3 and 4. DESIGN: A retrospective cohort study (Canadian Task Force classification II-2). SETTING: A tertiary referral center for hysteroscopic surgery. PATIENTS: Seventy-one patients with intrauterine permanent adhesions. INTERVENTIONS: Hysteroscopic surgery with monopolar energy (n=31) or bipolar energy (n=40). Uterine cavity with at least one free ostial area was restored after one (n=31), two (n=20), three (n=15), or four or more (n=5) surgical procedures RESULTS: Sixty-four patients were followed. Evaluation of the uterine cavity after surgery has been performed by hysteroscopy for all the patients. All patients had resumption of menses, except for two patients with a history of uterine artery embolization. Pregnancy index rate after the procedure was 28 (43.8%) of 64, and the live birth rate was 21 (32.8%) of 64. In patients 35 years of age or younger, 20 of 30 (66.6%) conceived compared with 8 of 34 (23.5%) in patients older than 35 years (p=.01). Three patients had either hysterectomy (n=2) or hypogastric arteries ligation for placenta accreta with uneventful postoperative course. CONCLUSIONS: Hysteroscopic adhesiolysis can be performed for severe adhesions stage 3 and 4 with safety and efficacy. Age is the main predictive factors of success: the pregnancies were at risk of abnormal placentation.

Determinants of patient dissatisfaction after a tension-free vaginal tape procedure for urinary incontinence.

PURPOSE: We identified the determinants of patient satisfaction after a tension-free vaginal tape procedure. MATERIALS AND METHODS: We retrospectively analyzed the records of 187 consecutive women with genuine stress (133) and mixed (54) incontinence. The objective cure rate was determined by clinical and urodynamic examination, and the subjective cure rate was assessed by a visual analog scale and the Contilife questionnaire. RESULTS: Mean followup was 27 months (range 6 to 34). The overall complication rate was 35.3%. The major perioperative and postoperative complications were bladder injury in 9.6% of cases, urinary retention in 6.4%, difficult voiding in 10.7% and new onset urge symptoms in 21.3%. The overall objective and subjective cure rates were 90.4% and 70.6%, respectively. The mean preoperative and postoperative visual analog scale score plus or minus standard deviation was 6.2 +/- 2.4 and 0.9 +/- 2.2, respectively (p = 0.0001). The subjective cure rate was significantly lower in women who underwent the procedure under general or spinal anesthesia than in those who received local anesthesia (p = 0.01). This difference was related to the rate of new onset urge symptoms. The mean postoperative visual analog scale score in women with and without new onset urge symptoms was 2.2 +/- 3.2 and 0.2 +/- 0.7, respectively (p = 0.0001). No difference in the subjective cure rate was detected according to patient age, menopausal status, previous incontinence surgery, the body mass index, additional procedures associated with tension-free vaginal tape surgery or the Ingelman-Sundberg classification. CONCLUSION: These results confirm that the tension-free vaginal tape procedure is associated with a high objective but lower subjective cure rate. The procedure performed using local anesthesia was associated with a lower incidence of difficult voiding and new onset urge symptoms.