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Modern gynaecology has witnessed a rapid evolution and a widespread application of endoscopic techniques over the past 20 years, particularly those seen in hysteroscopy. This has been made possible mainly due to technological developments relating to instrumentation and equipment, along with continuous improvements related to surgical techniques. The advances in technology and techniques, have made hysteroscopy less painful, less invasive and an outpatient procedure . Together with transvaginal ultrasound it provides the gold standard for diagnosis of uterine pathology.
Hysteroscopy enlarges the diagnostic capacity by minor surgical operative procedures like removal of IUD, biopsy or removal of polyps and minor synechiolysis.
This chapter provides a description of basic hysteroscopic procedures including simple operative procedures like second- and third-generation endometrial ablation and grade 0 to grade 1 myomectomy for small myomas.
The improvements in techniques, endoscopic instrumentation and surgical experience have completely changed the approach to uterine intracavitary pathologies, allowing the physician to achieve more reliable diagnostic and therapeutic results. The advent of these new technologies allows us today to improve advanced hysteroscopic surgery by increasing the efficacy of an operating room environment but avoiding the need for the inpatient setting for most of the procedures. It is possible to treat severe cervical stenosis or intrauterine synechiae, including Asherman’s syndrome, G2 myomas, congenital uterine malformations, adenomyosis and chronically retained products of conception in an ambulatory setting. The future looks to further the simplification of instrumentation, and establish a safer and easier delivery of energy sources.
This chapter provides a description of advanced hysteroscopic procedures and their benefits in modern gynaecological practice.
The purpose of uterine cavity evaluation is to make an accurate diagnosis of the cause of abnormal uterine bleeding, in order that therapy can be appropriately tailored to the woman. This chapter reviews the accuracy and efficacy of currently available tests used to evaluate the uterine cavity. Uterine size can be assessed on bimanual examination; if the uterus is greater in size than 12 weeks of gestation, it may be palpable abdominally. Women with amenorrhoea (no menstrual bleeding for 6 months) should have a full history and examination. Dilatation and curettage (D&C) used to be the method of choice for assessing the uterine cavity. Other methods for assessing the uterine cavity include hysteroscopy, ultrasound, Doppler ultrasound, and outpatient endometrial biopsy. Women presenting with postmenopausal bleeding require urgent referral for pelvic ultrasound and further testing, with endometrial biopsy and/or hysteroscopy undertaken depending on the initial ultrasound result.
Usually investigation for infertility is carried out by gynecologists, because if a couple failed to conceive it has been traditionally expected that the woman has a problem and should visit a doctor. The general examination starts when the patient comes into the consulting room from observations of body habitus, skin, hair excess, gait and posture. Ultrasonography is a more accurate method compared with bimanual examination so more precise data about ovaries and uterus may be obtained with a transvaginal ultrasound probe than with palpation. The assessment of ovulation involves history, examination and investigation. At hysterosalpingography (HSG) radio-opaque dye is injected through the small canula via the cervix into the uterine cavity under X-ray screening. In patients with infertility, diagnostic hysteroscopy is usually combined with laparoscopy. X-chromosome abnormalities may affect fertility in women with Turner syndrome, especially in mosaic form.
Recurrent miscarriage (RM) affects between 1-2% of fertile couples and is a clinical condition of heterogeneous etiology. Parental structural chromosome rearrangements are reported in 3-8% of couples suffering recurrent miscarriage and testing of both partners is therefore recommended. Conventional cytogenetic analysis of miscarriage tissue from women with a history of RM has detected a 26-57% abnormality rate. In the RM population, the prevalence of reported uterine malformations range widely from between 1.8% to 37.6%. Diagnostic tools for detecting uterine anomalies include two- and three-dimensional ultrasound, hysteroscopy, laparoscopy and magnetic resonance imaging (MRI). The antiphospholipid syndrome (APS) remains entrenched as one of the most studied factors associated with RM. Natural killer (NK) cells are found in peripheral blood and within the endometrium and have been associated with RM. Presently, many of the RM investigations are controversial because of limited studies, inconsistent terminology and small and poorly designed treatment studies.
The incidence of congenital uterine anomalies in the general population is between 0. 4% and 3. 2%. This chapter describes the principles of ultrasound diagnosis of uterine anomalies and compares the results with other available diagnostic modalities. The gold standard in the diagnosis of congenital uterine anomalies used to be a simultaneous laparotomy/ laparoscopy and hysteroscopy to visualize the serosal surface of the uterus and the endometrial cavity. The real breakthrough in ultrasound assessment of congenital uterine anomalies was the development of three-dimensional transvaginal probes. This technique involves the acquisition and storage of a volume of ultrasound information. Magnetic resonance imaging (MRI) has been shown to be effective for the diagnosis of congenital uterine anomalies with sensitivity and specificity up to 100%. The advent of three-dimensional ultrasound has greatly enhanced the ability to diagnose congenital uterine anomalies in an outpatient setting.
The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups according, respectively, to whether the septum approaches the internal os or does not. The complete septum that divides both the uterine cavity and the endocervical canal may be associated with a longitudinal vaginal septum. Although surgery (hysteroscopy, alone or with laparoscopy), constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis, with high levels of accuracy. In infertility patients it is believed that incidentally discovered uterine septum and even arcuate uterus should be corrected hysteroscopically prior to any infertility treatment to enhance reproductive outcome. While the hysteroscopic approach for surgical resection of uterine septum is safe and effective, the choice of surgical technique (using sharp scissors or electrocautery) is an operator preference.
Fertiloscopy is performed as an ambulatory technique. There are five steps in this procedure: hydropelviscopy, dye test, salpingoscopy, microsalpingoscopy, and hysteroscopy. One of the prerequisite of operative fertiloscopy was to be as effective as the same procedure practiced during laparoscopy. Compared to laparoscopy, fertiloscopy has also some advantages like the facility to perform salpingoscopy and microsalpingoscopy. Fertiloscopy was first designed to avoid diagnostic laparoscopy. Operative possibilities were developed later. The complication rate is low, almost always avoidable if contraindications are strictly respected. Endometriosis may also be treated by operative fertiloscopy, when minimal or moderate. If the lesions are extensive or severe, then laparoscopy has to be the preferred option. Some techniques like fertiloscopic ovarian drilling in polycystic ovarian syndrome (PCOS) patients have already demonstrated its interest in the pregnancy rate obtained without the risks of ovarian hyperstimulation syndrome (OHSS).
Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. Decreased fecundity with increasing female age has long been recognized in demographic and epidemiological studies. Traditionally, the evaluation of the infertile female consists of: (i) ovulation assessment (ovulatory factors), (ii) evaluation of the uterine morphology (ovulation assessment) and tubal patency (tubal factors), (iii) assessment of the presence of pelvic pathology (by laparoscopy) (peritoneal factors), and (iv) postcoital test (cervical factors). Hysterosalpingography (HSG), laparoscopy are widely used in assessing infertility. Chlamydia antibody testing is a screening method for assessing tubal infertility. HSG, sonohysterography, hystero-salpingo contrast sonography (HyCoSy), magnetic resonance imaging (MRI) and hysteroscopy are used in assessment of uterine factors related to infertility. Currently, the best method to monitor ovulation is transvaginal ultrasound, which can be used to demonstrate the growth of a dominant follicle and provide presumptive evidence of ovulation and leutinization.
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