Prevalence and risk factors for chronic endometritis in patients with adenomyosis and infertility: a retrospective cohort study.

BACKGROUND: To explore the incidence of chronic endometritis (CE) in patients with infertility and different forms of adenomyosis and analyze potential high-risk factors for infection. METHODS: This retrospective cohort study included 154 patients with infertility in the Liuzhou Maternity and Child Healthcare Hospital. Among them, 77 patients with adenomyosis were divided into four subgroups based on magnetic resonance imaging (MRI): internal, exterior, intramural, and full-thickness. Meanwhile, 77 patients did not have adenomyosis. Hysteroscopy and endometrial biopsy were performed in the proliferative phase. The main outcome measures were the morphology of the endometrium, syndecan-1 (CD138) immunohistochemical staining, clinical characteristics, and prevalence of CE in the adenomyosis subgroups. RESULTS: In comparison to the non-adenomyosis group, the adenomyosis group had significantly higher body mass index (BMI) and CA125 levels. The menstrual cycle in the adenomyosis group was significantly shorter, and menarche was significantly earlier. In comparison to the non-adenomyosis group, the adenomyosis group had a significantly higher diagnostic rate of CE (75.3% vs. 46.8% according to hysteroscopy and 74.0% vs. 33.8% according to histopathology, both with p < .050). The incidence of CE was significantly lower in patients with internal adenomyosis when compared with the other three subgroups. Increased BMI contributed to a higher risk of CE. CONCLUSIONS: The prevalence of CE was significantly higher in patients with adenomyosis and infertility. The differences in the incidence of CE are closely associated with the classification of adenomyosis. When patients with infertility are diagnosed with adenomyosis, it is recommended to identify the subtype and screen for endometritis.

Hysteroscopic Endometrial Fundal Incision versus Hysteroscopy Only in Oocyte Recipients: A Randomized Controlled Trial Assessing The Reproductive Outcomes.

BACKGROUND: Endometrial scratching (ES) remains controversial regarding its potential effectiveness in improving pregnancy rates. The objective of the present study was to assess the impact of endometrial fundal incision (EFI) during hysteroscopy on reproductive outcomes in a population of oocyte recipients. MATERIALS AND METHODS: A randomized controlled trial was conducted between 2020 and 2023 at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki and "Assisting Nature Centre of Reproduction and Genetics". The study population consisted of women who underwent hysteroscopy randomly assigned in a 1:1 ratio to either EFI (one to three months before embryotransfer with donor oocytes) or no intervention throughout office hysteroscopy. Clinical pregnancy and live birth rates were the primary outcomes. RESULTS: After the exclusion of patients with intraoperative diagnosed endometrial pathology, a total of 124 women underwent randomization. The pregnancy test was positive in 79% (n=49/62) of the women in the EFI compared to 59.7% (n=37/62) in the hysteroscopy-only group (P=0.019), while the live birth rates did not differ between the two groups (58.1%, n=36/62 vs. 51.6%, n=32/62, P=0.470). CONCLUSION: EFI during hysteroscopy seems to improve pregnancy rates in oocyte recipients without intrauterine pathology, while live birth rates are not affected by the EFI. These results should be interpreted with caution before the implementation of EFI in the routine in vitro fertilization (IVF) practice (registration number: NCT04580056).

Characteristics of hysteroscopic training models: A review of the literature.

Objectives: The purpose of this review is to summarize the characteristics and applications of current hysteroscopic training models. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library for eligible studies published before March 2024. Manual screening of references and citation tracking were also performed. Results: Reported hysteroscopic training models included virtual reality simulators, non-biological material models, plant tissue models, animal tissue models, and human tissue models. No training model was distinctly superior in terms of realism, haptic feedback, availability of standardized scoring of operations, preparation difficulty, reusability of surgical procedure, and prices. Utilizing any type of models for hysteroscopy simulation training could assist trainees in enhancing relevant knowledge, skills, self-confidence, and comfort, but virtual reality models had an advantage in training capacity. Conclusions: Each hysteroscopic training model has its advantages and disadvantages. An appropriate training curriculum is needed to efficiently leverage the merits of different models. The realism and training effectiveness of various training models need to be compared using rigorously designed studies and standard evaluation tools.

Paradoxical air embolism in patients undergoing hysteroscopic surgery for cesarean scar pregnancy: A case report and review of the literatures.

Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low-resistant, high-velocity blood vessels.

Effectiveness of degradable polymer film in the management of severe or moderate intrauterine adhesions (PREG-2): a randomised, double blind, multi-centre, stratified, superiority trial.

OBJECTIVE: To study the effectiveness of a new intrauterine degradable polymer film (Womed Leaf®) in the management of moderate to severe IUA. DESIGN: PREG2 study was a multi-centre, double-blind, randomised, controlled, stratified, two-arm superiority clinical trial conducted in 16 centres in 7 countries. SUBJECTS: Patients ≥18 years scheduled for hysteroscopic adhesiolysis because of symptomatic severe or moderate adhesions (according to American fertility society (AFS) IUA score) were considered eligible for the study. INTERVENTION: Following adhesiolysis, patients were randomised at a 1:1 ratio to either have a Womed Leaf film inserted (intervention group) or not (control group). MAIN OUTCOME MEASURES: The primary effectiveness endpoint of the study was the change in AFS IUA score on second-look hysteroscopy (SLH), assessed by an independent evaluator, compared to baseline. Information on rate of no IUA and responder rate were collected as secondary effectiveness outcomes, and reported adverse events and patient reported outcomes as safety and tolerability measures. RESULTS: Between October 26, 2021, and September 28, 2023, a total of 160 women were randomised (Womed Leaf: n=75 and controls: n=85). The reduction in IUA AFS score on SLH was significantly higher in the intervention compared to the control group (mean 5.2 ± 2.8 vs. 4.2 ± 3.2; p=0.0153). Similarly, the absence of adhesions on SLH was significantly higher in the intervention group (41% vs 24% OR 2.44 [CI 1.161 - 5.116]; p=0.0189). None of the reported adverse events were serious or considered related to the device. CONCLUSION: Womed Leaf is effective and safe in the management of symptomatic severe or moderate intrauterine adhesions.

Methoxyflurane analgesia for outpatient hysteroscopy: A double-blind, randomised, controlled trial.

BACKGROUND: Despite clinical and economic benefits, pain during outpatient hysteroscopy (OPH) remains a barrier to use. There is a lack of evidence to support routine use of one analgesic over another versus no analgesic. AIMS: To study the efficacy and safety of methoxyflurane analgesia during OPH. MATERIALS AND METHODS: A single-centre, randomised, double-blind, placebo-controlled experiment was performed; 90 patients were randomly assigned (1:1). Participants allocated to the treatment group (cases) received 3 mL of methoxyflurane through an inhaler. The control group received a placebo. The primary outcome was a mean difference in pain, via a change in Visual Analog Scale (VAS) score from baseline at diagnostic hysteroscopy. Secondary outcomes were a mean difference in VAS score with any subsequent operative procedures; a mean difference in VAS score at 15 min post-procedure; participant and clinician-reported adverse effects and events; and participant-reported procedure acceptability, adjuvant nitrous oxide (N2O2) use and a composite of 'distress'. RESULTS: During diagnostic hysteroscopy, there was a mean difference of 11.5 mm/100 (95% confidence interval (CI) 0.08-22.95), P = 0.05, with the lower score in the cases, compared with controls. During subsequent operative procedures, there was a mean difference of 15 mm/100 (95% CI 2.71-28.22), P = 0.02, with the lower pain score in the cases, compared with controls. There was no significant difference in pain 15 min post-procedure, participant- and clinician- reported adverse effects and events, procedure acceptability and the 'distress' composite. CONCLUSIONS: Methoxyflurane significantly reduced pain during OPH compared with placebo, for diagnostic as well as operative procedures. Furthermore, methoxyflurane was well tolerated, with no adverse events.

The Effect of a Short Training Course of Hysteroscopic Myoma Resection on the Non-Technical Skills of Gynecologic Surgeons.

Objective: To assess the impact of a hysteroscopic myoma resection (HMR) two-day training course on non-technical (cognitive) surgical skills among gynecologists. Materials and methods: A 2-day educational course was held in which 95 consultant gynecologic surgeons and beginner infertility fellowship residents took part. Among all 80 participants (84.2%) had ever performed diagnostic hysteroscopy and 30 (31.3%) had performed non-resectoscopic operative hysteroscopy. The training program included instructive speeches, simulated surgical presentations, and a live hands-on myomectomy workshop. Non-technical skills were assessed two times, once before and the other after the course through two written tests with 10 multiple-choice questions for each. Results: Concerning the 95 participants, 43 (47.3%) took the pre-course test and all of them (100%) took the post-course one. The mean score improved significantly from 3 (interquartile range [IQR], 0-4.0) to 7 (IQR, 5.0- 8.0) [bootstrap p<0.0001] for each of the randomly chosen pairings. The majority of candidates showed significantly improved cognitive skills after the HMR course despite their poor cognitive skills before the course. According to further analysis, there were significant enhancements in grades for all topics, especially regarding the basic principles of the procedure and management of complications (bootstrap p<0.0001). The odds ratio for the pre- versus post-course mean test results was 5.23. Due to the confidentiality stipulation, the pre- and post-course scores were not matched. Conclusion: A two-day continuing medical educational course could be efficient in improving the nontechnical (cognitive) skills for HMR.

The efficacy of early office hysteroscopy in preventing intrauterine adhesions after abortion: a randomized controlled trial.

BACKGROUND: Intrauterine adhesions (IUA) are a challenging clinical problem in reproductive infertility. The most common causes are intrauterine surgery and abortions. We aimed to investigate whether early second-look office hysteroscopy can prevent IUA. METHODS: A single-center, prospective, two-armed, randomized controlled trial was designed to explore the efficacy of early office hysteroscopy after first-trimester induced abortion (suction dilatation and curettage [D&C]) and to further analyze fertility outcomes. Women aged 20-45 years undergoing suction D&C and desiring to conceive were recruited. Between October 2019 and September 2022, 66 women were enrolled, of whom 33 were allocated to group A (early hysteroscopy intervention). The women in intervention group A were planned to receive 2 times of hysteroscopies (early and late). In group B, women only underwent late (6 months post suction D&C) hysteroscopy. RESULTS: The primary outcome was the IUA rate assessed using office hysteroscopy 6 months after artificial abortion. Secondary outcomes included menstrual amount/durations and fertility outcomes. In intervention group A, 31 women underwent the first hysteroscopy examination, and 15 completed the second. In group B (late hysteroscopy intervention, 33 patients), 16 completed the hysteroscopic exam 6 months after an artificial abortion. Twenty-one women did not receive late hysteroscopy due to pregnancy. The IUA rate was 16.1% (5/31) at the first hysteroscopy in group A, and no IUA was detected during late hysteroscopy. Neither group showed statistically significant differences in the follow-up pregnancy and live birth rates. CONCLUSIONS: Early hysteroscopy following suction D&C can detect intrauterine lesions. IUA detected early by hysteroscopy can disappear on late examination and become insignificant for future pregnancies. Notably, the pregnancy outcomes showed a favorable trend in the early hysteroscopy group, but there were no statistically significant differences. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT04166500. Registered on 2019-11-10. https://clinicaltrials.gov/ct2/show/NCT04166500 .

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.

Chronic endometritis - a constantly discussed issue in infertile women.

OBJECTIVE: A review of current knowledge on the pathophysiology, diagnostic and treatment options for chronic endometritis in infertile women. METHODS AND RESULTS: One of the major causes of failed in vitro fertilization (IVF) is undiagnosed intrauterine pathologies, including chronic inflammation of the uterine mucosa - chronic endometritis. However, some authors relativize the negative impact of chronic endometritis on reproductive outcomes. The etiopathogenesis of chronic endometritis is due to qualitative and quantitative changes in the endometrial microbiome with abnormal multiplication of microorganisms naturally occurring in the uterine cavity or vagina. There is no uniform consensus on the most common pathogen causing chronic endometritis. It is characterized by infiltration of plasma cells into the endometrial stroma outside the menstrual cycle, accompanied by hyperaemia and endometrial oedema. Clinical symptoms are very mild or absent. The diagnosis of chronic endometritis is often difficult because there is no specific clinical or laboratory diagnostic method. The following investigative options are commonly used for the diagnosis of chronic endometritis: diagnostic hysteroscopy, histopathological examination of the endometrium including CD 138 immunohistochemistry and culture from the uterine cavity. However, standardised international hysteroscopic and histopathological criteria for accurate diagnosis of chronic endometritis are still lacking. Empirically administered antibiotic therapy improves the success rate of pregnancy and delivery of a viable foetus in infertile patients with proven chronic endometritis. In addition to reviewing the current knowledge of chronic endometritis, this article discusses the importance of hysteroscopy in the diagnostic process. CONCLUSION: Chronic endometritis is often a clinically silent disease with negative impact on reproduction in infertile women. Although there are still many unresolved issues, the introduction of hysteroscopy into the diagnostic process is important for clinical practice; however, hysteroscopy even in combination with histological examination of the endometrium, often does not allow an unequivocal diagnosis of chronic endometritis. Further prospective randomised studies in a selected group of women with proven chronic endometritis and repeated failure to implant proven euploid embryos should refine this knowledge.

Systematic evaluation of the efficacy of treatments for cesarean scar pregnancy.

STUDY OBJECTIVE: Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy associated with severe complications, including significant hemorrhage, the potential need for hysterectomy, and life-threatening risks. Currently, two classification methods exist for CSP: Vial (type Ia and IIa) and Chinese Expert's Consensus (type Ib, type IIb, and type IIIb). However, these methods have limitations in guiding the selection of appropriate treatment plans for CSP. The purpose of this study was to systematically evaluate the effectiveness of various treatments for CSP within our clinic. METHOD: Our study included 906 patients with CSP from January 2013 to December 2018. The chi-squared test and logistic analysis were used to compare the clinical characteristics. The median and interquartile range (IQR) was calculated. We also analyzed whether preoperative application of methotrexate (MTX) could improve surgical outcomes and the relevant characteristics of misdiagnosed CSP patients. RESULTS: There was a significant difference in gestational age, gestational sac diameter, gestational sac width, gestational sac area, remnant myometrial thickness, vaginal bleeding and preoperative hemoglobin levels (p < 0.001) but not in the incidence of residual tissue (p = 0.053). The other factors (intraoperative blood loss, hemoglobin decline, first hemoglobin after operation, total hospital stay, hospital stay after operation, transfusion and duration of catheter drain) were significantly different (p < 0.001). For type Ia and type Ib CSP, 39.3% and 40.2% of patients were treated with dilatation and curettage (D&E) under ultrasound, respectively. For type IIa and type IIIb CSP, 29.9% and 62.7% of patients were treated with laparotomy, respectively. There were no differences in surgical methods, residual tissue and reoperation between the MTX and non-MTX groups (p = 0.20), but liver damage, hospital stay and pain perception were more remarkable in the MTX group. It is noteworthy that 14% of the patients were misdiagnosed with an intrauterine pregnancy. The incidence of misdiagnosis in type IIa CSP patients was higher than that in type Ia CSP patients (p < 0.001). CONCLUSION: For type I CSP patients, D&E under ultrasound or D&E under hysteroscopy should be recommended. For type IIIb CSP patients, operative resection should be used. It is currently difficult to choose the appropriate treatment methods for type IIa or type IIb CSP patients.

Guideline No. 451: Asymptomatic Endometrial Thickening in Postmenopausal Women.

OBJECTIVE: To formulate strategies for clinical assessments for endometrial thickening on ultrasound in a postmenopausal woman without bleeding. TARGET POPULATION: Postmenopausal women of any age. OUTCOMES: To reduce unnecessary invasive interventions and investigations in women with asymptomatic endometrial thickening while selectively investigating women at risk for endometrial cancer. BENEFITS, HARMS, AND COSTS: It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complications. It is also expected to decrease the cost to the health care system by eliminating unnecessary interventions. EVIDENCE: English language articles from Medline, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1995 to 2022 (e.g., asymptomatic endometrial thickness, endometrial cancer, postmenopausal bleeding, transvaginal ultrasound, endometrial biopsy, cervical stenosis, hormone therapies and the endometrium, tamoxifen, tibolone, aromatase inhibitors). Results were restricted to systematic reviews and meta-analyses, randomized controlled trials/controlled clinical trials, and observational studies. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Physicians, including gynaecologists, obstetricians, family physicians, radiologists, pathologists, and internists; nurse practitioners and nurses; medical trainees, including medical students, residents, and fellows; and other providers of health care of the postmenopausal population. SOCIAL MEDIA ABSTRACT: Postmenopausal women often have a thickening of the lining of the uterus found during ultrasound. Without bleeding, an endometrium <11 mm is rarely a serious problem but should be evaluated by a health care provider. SUMMARY STATEMENTS: RECOMMENDATIONS.

Primary Malignant Melanoma of The Endocervix Uteri and Outpatient Hysteroscopy as a Diagnostic Tool: Case Report and Literature Overview.

Mucosal malignant melanoma has a low incidence and only 2% are diagnosed in the gynecological tract. Diagnosis of primary cervical malignant melanoma is often challenging. The clinical presentation mimics other malignant cervical tumors, usually with abnormal bleeding or discharge. Cervical screening tests, such as cytology, often fail to detect malignant melanomas because of the rarity of the disorder, and histological evaluation of lesions is of paramount importance. The treatment is often based on regimens used for cutaneous malignant melanoma. We present the first case in the literature of primary malignant melanoma of the endocervix diagnosed by outpatient hysteroscopy and we have performed a narrative review of the literature on PubMed, Scopus and Web of Science from 1980 to December 2023, identifying 137 cases. The most common initial symptom was vaginal bleeding in 82.8% of cases, and 84.8% of patients were menopausal at the time of diagnosis. The first diagnostic modality was biopsy in 67.7%; 90% of patients underwent surgery and 64.5% of the deaths occurred within the first 12 months after diagnosis. Primary malignant melanoma of the cervix is extremely rare and difficult to diagnose at an early stage which is due to the aggressiveness of the disease and the non-specificity of the symptoms. To improve survival, early diagnosis is essential and hysteroscopy could be a useful tool in achieving it. It is crucial to increase the attention of gynecologists on primary malignant melanoma of the cervix to also perform a diagnostic hysteroscopy in case of doubtful symptoms.

Diagnostic accuracy and characteristics of symptomatic versus asymptomatic retained products of conception: A retrospective cohort study.

OBJECTIVE: To assess the accuracy of diagnosing retained products of conception (RPOC) in symptomatic versus asymptomatic women, and to identify potential divergent ultrasound features between these groups. METHODS: This retrospective study included women aged 17-50 years who underwent hysteroscopy for suspected RPOC during 2018-2021. Clinical and sonographic data were analyzed, and multivariable linear regression models employed, to examine correlations between RPOC and sonographic findings, and to compare diagnostic accuracy between symptomatic and asymptomatic women. RESULTS: Of the 225 women included, 123 (54.7 %) were symptomatic and 102 (45.3 %) were asymptomatic. Hysteroscopy complications were more frequent in asymptomatic women. Regarding sonography, statistically significant differences were not found between the groups in endometrial thickness or uterine fluid presence, but positive Doppler flow was more common in asymptomatic than symptomatic women. Endometrial thickness >1.49 cm demonstrated diagnostic utility, with similar sensitivity and specificity in the two groups. Multivariable models revealed significant associations of RPOC presence with endometrial thickness and Doppler flow in symptomatic women. In both groups, hysteroscopy enhanced diagnostic accuracy, with higher positive predictive values and lower false-positive rates compared to ultrasound alone. CONCLUSION: An endometrial thickness cutoff of 1.49 cm aids diagnosing RPOC. Doppler flow enhances diagnostic value in symptomatic women. Integration of hysteroscopy improves diagnostic accuracy compared to ultrasound alone. Regular sonographic assessment for women with identifiable risk factors assists in RPOC detection irrespective of symptoms.

Efficacy of hysteroscopic levonorgestrel­releasing intrauterine device fixation in the treatment of adenomyosis: A cohort study.

The present study aimed to investigate the efficacy of hysteroscopic levonorgestrel-releasing intrauterine device (LNG-IUD) fixation surgery in the treatment of adenomyosis through a cohort study. The cohort study was performed at the Affiliated Jinhua Hospital of Wenzhou Medical University (Jinhua, China). A total of 31 women with adenomyosis were initially recruited from June 2020 to June 2022 and divided into an experimental group and a control group. The experimental group underwent hysteroscopic LNG-IUD fixation surgery and the control group underwent conventional implantation of the levonorgestrel-releasing intrauterine system. The assessed efficacy outcomes included the time of LNG-IUD expulsion, postoperative vaginal bleeding time, dysmenorrhea, and the menstrual blood loss score (MBLS). A total of 31 participants completed the research. The LNG-IUD expulsion rate was 6.25 and 60% (P<0.05) in the experimental and control group, respectively. The LNG-IUD in place time was 20.50 months (Q1, 15.75; Q3, 24.00) in the experimental group and 10.00 months (Q1, 6.50; Q3, 15.00) in the control group (P<0.05); the time of vaginal bleeding after surgery in the experimental and control groups were 12.50 days (9.25, 16.25) and 120.00 days (75.00, 120.00), respectively (P<0.05). Multiple-factor Cox regression analysis revealed that the LNG-IUD expulsion in patients with adenomyosis is associated with the hysteroscopic LNG-IUD fixation surgery [hazard ratio (HR), 1954.09], uterine cavity depth (HR, 16.63), MBLS (HR, 1.14), history of gonadotropin-releasing hormone agonist treatment in the previous 6 months (HR, 2.10), history of vaginal delivery (HR, 1.79) and history of cervical laceration (HR, 3.69). In conclusion, hysteroscopic LNG-IUD fixation reduces the rate of LNG-IUD expulsion, prolongs the time of LNG-IUD in the uterine cavity, reduces the time of postoperative vaginal bleeding, relieves the symptoms of dysmenorrhea and reduces the menstrual volume in the patients with adenomyosis. The present trial was retrospectively registered in the Chinese Clinical Trial Registry on 28th December 2023 (registration no. ChiCTR2300079233).

"RAIL BIOPSY" A Novel and Useful Technique for Hysteroscopic Endometrial Target Biopsy.

STUDY 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 [1-3]. 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 an adequate specimens 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. DESIGN: A step-by-step explanation of surgical techinque with narrated video footage. SETTING: Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero-Universitaria di Bologna" Bologna, Italy. 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 the 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 the 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. VIDEO ABSTRACT.

The use of oral nomegestrol acetate/estradiol in rapid and random start preparation of endometrium before office hysteroscopic polypectomies: A multicenter, prospective, randomized controlled trial.

OBJECTIVE: To evaluate the use of oral nomegestrol acetate/estradiol in random start rapid preparation of endometrium before office hysteroscopic polypectomy. STUDY DESIGN: Multicenter, prospective, randomized controlled trial. SETTING: University hospitals. PARTICIPANTS: 80 adult women undergoing office hysteroscopic polypectomy between January 2023 and March 2024 were randomized to intervention (n = 40) or control (n = 40). Exclusion criteria included the presence of endouterine pathology other than endometrial polyps solely. METHODS: Subjects in the intervention group were treated with oral nomegestrol acetate/estradiol 1.5 mg/2.5 mg/day started taking the drug from an indefinite time in the menstrual cycle (random start) for 14 days. Subjects in the control group did not receive any pharmaceutical treatment and underwent polypectomy between days 8 and 11 of the menstrual cycle. RESULTS: On the day of the procedure, the difference in pre- and post-office hysteroscopic polypectomy endometrial ultrasound thickness was statistically significant between the two groups, with endometrial thickness in both measurements being thinner for the intervention group (p < 0.001). In the nomegestrol acetate/estradiol-treated group, compared with the control, there was also a statistically significant difference in the physician's assessment of the quality of endometrial preparation (p < 0.001), the quality of visualization of the uterine cavity (p < 0.001), and satisfaction with the performance of the procedure (p < 0.001). Finally, all surgical outcomes analyzed were better in the treatment group. CONCLUSION: Treatment with nomegestrol acetate/estradiol could provide rapid, satisfactory and low-cost preparation of the endometrium before office polypectomy, thus improving surgical performance and woman's compliance. TRIAL REGISTRATION: ClinicalTrials.gov NCT06316219.

Comparison of laparoscopic and hysteroscopic surgical treatments for isthmocele: A prospective cohort.

Objective: To evaluate the clinical outcomes of laparoscopic and hysteroscopic surgical approaches for treating symptomatic isthmocele and identify their associated factors. Materials and Methods: Forty-six patients with symptomatic isthmocele diagnosed using transvaginal saline infusion sonohysterography were enrolled in this prospective cohort study. Patients underwent either laparoscopic or hysteroscopic isthmoplasty based on their residual myometrial thicknesses and fertility desires and were subsequently followed by clinical and ultrasonographic examinations. Results: Twenty-two patients underwent laparoscopy and 24 underwent hysteroscopic surgery. At baseline, there was no significant difference in the mean age and years since the last cesarean section between the two groups. However, the hysteroscopy group had a higher mean parity and previous cesarean sections (p=0.00, 0.03). The most common symptoms were abnormal uterine bleeding, infertility, and dysmenorrhea. The mean baseline residual myometrial thickness was significantly higher in the laparoscopy group (p=0.00), and only laparoscopic surgery led to a significant increase in residual myometrial thickness in patients (p=0.00). Both procedures significantly reduced abnormal uterine bleeding (p=0.00), but only laparoscopy reduced infertility (p=0.00) and hysteroscopy reduced dysmenorrhea (p=0.03). Hysteroscopy showed better symptom resolution in younger patients (p=0.01), whereas age did not affect laparoscopy outcomes. Conclusion: Both approaches showed similar effectiveness in resolving abnormal uterine bleeding, with laparoscopy excelling in infertility resolution and hysteroscopy excelling in dysmenorrhea resolution.

Natural conception and term pregnancy after hysteroscopic incision of complete septate uterus with septate cervix: A case report and literature review.

OBJECTIVE: To discuss several techniques of hysteroscopic surgery for complete septate uterus. CASE REPORT: A 40-year-old female with unexplained primary infertility was diagnosed with complete septate uterus with septate cervix. Hysteroscopic incision of complete septate uterus was performed by using ballooning technique. The patient conceived naturally shortly after the operation and delivered a healthy, term infant. CONCLUSION: Hysteroscopic incision of complete septate uterus is a safe and prompt way of metroplasty. With the knowledge obtained from a pre-operative MRI, it can be completed without laparoscopy and the need for hospitalization.