Hysteroscopic Evaluation of Different Types of Healing of the Uterine Incision for Caesarean Section

Abstracts / Journal of Minimally Invasive Gynecology 16 (2009) S103eS157 Study Objective: To study the factors that play a role in the decision of physicians to choose between Hysteroscopic sterilization (HS)(EssureÒ)and other methods of achieving permanent sterilization. Design: A questionnaire-based survey of attending physicians providing contraceptive services. Setting: Department of Obstetrics and Gynecology at a community hospital. Patients: None Intervention: Paper questionnaire was completed by subjects and their responses analyzed. Measurements and Main Results: Of the 68 physicians surveyed, 35 responded (51.47%). They graduated from residency between 1968 to 2008. 21 (60%) performed HS and 14 (40%) did not. Only 10/35 (28.57%) physicians offered HS as an option to all patients. According to 24/35 (68%) physicians, friends were the most common source of patient knowledge before talking to the doctor. Only 4/21 preferred to perform HS in an office setting, even though 11/21 stated that as the main reason why they prefer HS.19/35 (54.3%) physicians stated that minimally invasive nature of HS was the main reason of their patients’ choice of HS.94.3% (33/35) believed that more training programs in HS will result in more physicians providing HS. Using a Pearson Product Moment Correlation Coefficient calculation, it was seen that the more patients that were offered HS, the higher the percentage of procedures that were done with HS (r 5 .563, p .002) and that the more recently the physician completed his/her residency, the more likely they are to perform HS (r 5 -.307, p .032). Conclusion: Recent graduates are more likely to provide HS than older physicians.The minimally invasive nature of HS is an important reason of patients choice of HS. Increased awareness and training amongst physicians will help in making HS more popular. An increase in sterilizations performed by HS is likely in near future as new graduates enter into practice.

412 Hysteroscopic Diagnosis and Management of Infertility Following Miscarriage and Delivery Argade KV. Gynec Endoscopy Training Center, Argade Hospital, Kolhapur, MS, India Study Objective: To evaluate usefulness of hysteroscopy in treatment of secondary infertility. Design: This was an observational study done at Maher Endoscopy Centre and Laparoscopy Training Centre, Kolhapur, India. Over the period of eight years, 4500 hysteroscopies were performed for primary and secondary infertility. Surgical technique included preoperative introduction of misopristol vaginally to facilitate opening of cervical canal. Gradual introduction of the hysteroscope by opening uterine cavity under hydro pressure inside the cervical canal. Adhesions are stretched and give way to open the uterine cavity, also have used suction curette for sucking adhesions. Setting: N/A Patients: N/A Intervention: N/A Measurements and Main Results: One patient developed secondary amenorrhoea following accidental injection of corrosive/chemicals for uterine artery meant for injecting vescical artery. Two patients had Foetal bones in the uterine cavity. Endometrial cavity was clear except flimsy adhesions. The bone acted like intra uterine device and patient conceived after removal. These bones were easily removed with hysteroscopic foceps. One patient had broken tip of Karmann Cannula in uterine cavity. Three patients had Bony metaplasia due to chronic endometritis following mid-trimester termination. Three cases presented with secondary amenorrhoea following LSCS. Their hormonal profile was normal suggesting uterine cause of amenorrhoea due to accidental inclusion of posterior wall of lower uterine segment. In all the cases intrauterine Foleys catheter was kept for 24 hours and in three cases a repeat hysteroscopy was performed.

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Conclusion: Hysteroscopy is an useful tool in diagnosis and management of infertility following miscarriage and delivery.

413 Evaluation of Quality of Life of Women One Year after Ablation of the Endometrium with Thermachoice Avella M,1 Deus A,1 Ayres T.2 1Histeroscopia, Endogin Endoscopia Ginecolo´gica, Sorocaba, Sa˜o Paulo, Brazil; 2Ginecologia, Hospital Evange´lico de Sorocaba, Sorocaba, Sa˜o Paulo, Brazil Study Objective: Evaluate the changes in the quality of life of women one year after thermal balloon endometrial ablation (Thermachoice). Design: By means of SF-36 Quality-of-life Instrument, we evaluated women presenting episodes of metrorrhagia that would be submitted to Thermachoice endometrial ablation. After a one year follow-up the patients were reevaluated following the same criteria of the first questionnaire. Setting: All the patients participating in the pilot project ‘‘Heat treatment with silicone balloon for metrorrhagia under local anesthesia’’ during the year of 2008 were primarily evaluated regarding their quality of life by use of the SF 36 questionnaire a little before the procedure. The patients were followed by phone calls concerning possible complaints and were submitted to the SF 36 again, six months and one year after the procedure.

Patients: The patients selected were the ones who presented dysfunctional uterine bleeding diagnosed in basic health care units and who were referred to surgical treatment. They were submitted to interview (SF 36 questionnaire applied) and underwent careful physical examination followed by ultrasonography in the patients who were apt to the procedure. The inclusion criteria are described below. Criteria for inclusion: Documental diagnosis of menorragias for benign causes Complete offspring Normal Pap smear Uterine cavity anatomically normal proven by ultrasound Uterine cavity between 4-12 cm Drug therapy on the treatment of menorragia has failed or against indicated Intervention: Patients were requested, through phone contact, to come for a new interview in which the SF 36 was once more applied by the same interviewer for data collection. Measurements and Main Results: Important improve was observed in the quality of life of these women in all the evaluation criteria with the exception of the general health and social aspects. Conclusion: According to this study the thermachoice treatment of metrorrhagias showed significant improve in the quality of life of the patients with one-year follow-up. 414 Hysteroscopic Evaluation of Different Types of Healing of the Uterine Incision for Caesarean Section Ceci O, Scioscia M, Pinto L, Laera AF, Achilarre MT, Camporeale AL, Vimercati A, Bettocchi S. Department of Obstetrics, Gynecology and Neonatology, University of Bari, Bari, BA, Italy Study Objective: To evaluate by hysteroscopy the different types of healing of the uterine incision for low segment caesarean section.

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Abstracts / Journal of Minimally Invasive Gynecology 16 (2009) S103eS157

Design: Prospective clinical study. Setting: University-affiliated hospital. Patients: Between January 2005 and December 2006, 88 singleton primiparae with an uneventful pregnancy who delivered at term (37-42 weeks) by low-segment caesarean section take part to this study. Recruited women had no history of previous uterine surgery or evidence of uterine malformation or myomas in the anterior lower segment, placenta previa, diabetes mellitus, chorioamnionitis, connective disorders (exclusion criteria). Intervention: All patients have been assessed by transvaginal ultrasound and hysteroscopy at the 24th month after delivery. Measurements and Main Results: Transvaginal sonographic assessment was performed in each case in order to ascertain the presence of the caesarean scar pouch. An office hysteroscopy was carried out on the same day to verify sonographic findings. Office hysteroscopy was performed with a 4-mm continuous-flow operative hysteroscope (Karl Storz, Germany) by vaginoscopic approach. At the 24th month the pouch was found by ultrasound in 72/78 (92.3%) patients and confirmed in all cases by hysteroscopy, but with different aspects: fibrosis in 46 cases (63.9%), hypertrophy with little endometrial polyps in 11 cases (15.3%), with signs of superficial neovascularisation in 8 cases (11.1%) and with the growth of endometrium on the internal surface in 7 cases (9.7%). Conclusion: In our study hysteroscopy has always confirmed the presence of the uterine defect revealed by ultrasonography, but showing different aspects. These various aspects could explain longterm complications of the caesarean pouch like uterine rupture or ectopic scar pregnancy with a placenta location on the lower anterior uterine wall where an endometrial vascularised tissue has re-grown. Undoubtedly caesarean scar defects are responsible also for postmenstrual bleeding due to a dark-blood collection beneath the scar pouch and secondary infertility.

415 The Relevance of Polypectomy in the Cases of Infertility Dias DS,1,2 Abra˜o F,1 Modotti WP,1,2 Modotti CC,1 Lasmar RB,1 Dias R.1 1 Gynecology, Obstetrics and Mastology, Botucatu Medical School Sa˜o Paulo State University - UNESP, Botucatu, Sa˜o Paulo, Brazil; 2IAM Instituto de Atendimentoa` Mulher, Assis, Sa˜o Paulo, Brazil Study Objective: To evaluate polypectomy by video-endoscopy as a method of treating patients with primary and secundary infertility. Design: Retrospective analysis of data obtained from medical records of patients who had already undergone diagnostic and surgical endoscopies at the Gynecological Endoscopy Sector from Botucatu Medical School UNESP, in 2004 and 2005. Setting: Botucatu Medical School Sa˜o Paulo State University - UNESP. Gynecological Endoscopy Ambulatory and Surgical Center. Patients: Fifty four (54) women submitted to hysteroscopy exam with a diagnosis of endometrial polyp and infertility were retrospectively analyzed. Epidemiology data, clinical features and the locatization and histology of polyps were evaluated. Intervention: Retrospective analysis of data. Measurements and Main Results: The mean age was 31-35 years; 50% had BMI of 20-25 (normal), 88.88% were white, 98.10% were nonsmokers, and 1.85% had arterial hypertension. Approximately 40% had cervical polyps associated with endometrial polyps. In 61.10% of cases endometrial polyps were on the anterior and posterior uterine walls. Guided biopsy found 11.11% of endometrial polyps which were all benign, and after polypectomy, anatomic pathology found benign polyps in 98.14% and atypical polyps in 1.85%. Primary sterility occurred in 77.77% and secondary in 33.33%. Pregnancy in the first year after polypectomy occurred in 31.4%, and ultrasound was normal in 24% of cases, previously the surgery. Conclusion: In all cases of infertility, primary or secundary, the ivestigation of the uterine cavity is necessary, even if the transvaginal ultrasound is normal. Despite of age atypical formations may occur. Patients with polyps will benefit from the removal of them.

416 Experience with Endometrial Ablation in Clinica Las Condes Duque GA, Albornoz JA, Hitschfeld CA, Fernandez EA. Obstetrics and Gynecology, Unit of Reproductive Medicine, Clinica Las Condes, Santiago, RM, Chile Study Objective: To report the results after partial endometrial ablation with resectoscope for benign gynecological conditions. Design: Retrospective analysis of the evolution of 12 patients after partial endometrial ablation. Setting: Unit of Reproductive Medicine, Clinica Las Condes-Chile. Patients: Twelve patients with a mean age of 44,7  5 years old underwent endometrial ablation for heavy menstrual bleeding, from January 2004 to December 2008. Intervention: Under general anesthesia, partial endometrial ablation with resectoscope was performed using a loop electrode connected to highfrequency electrical monopolar current which shaved off the anterior or posterior endo-miometrial surface. Manitol/Sorbitol was used as distention media and the fragments were removed from the uterine cavity. Measurements and Main Results: The operating time was 42  15 minutes and no complications were observed, either during or after the procedure. Mean follow-up time was 22 months (2-72 months) and during this period, 50% of the patients reported light periods. In turn 33.3% (4/12) of the patients evolved with heavy menstrual bleeding and histopathology report showed submucous myoma in 2 patients, adenomyosis in one patient and proliferative endometrium in one patient. In three out of twelve patients (25%), a second surgical procedure was required because of heavy menstrual bleeding: repeated endometrial ablation in 2 cases and total hysterectomy in one case. In another patient, histopathology informed a G1 endometrial cancer and total hysterectomy was performed at 2 months from the first surgery. Conclusion: Endometrial ablation is an alternative to hysterectomy in case of heavy menstrual bleeding in women who wish to preserve the uterus. Although endometrial ablation with resectoscope is a safe procedure in experienced hands, up to one third of the patients will require a new surgical treatment in the future. If abnormal histological findings are encountered, radical surgery can be performed afterwards.

417 Feasibility of Hysterosalpingography To Evaluate Tubal Occlusion Following Concomitant AdianaÒ Transcervical Sterilization and NovaSureÒ Endometrial Ablation Garza-Leal J,1 Hernandez I,1 Castillo L,1 Livengood R,2 Stillman M,3 Coad JE.2 1Department of Gynecology, Universidad Auto´noma de Nuevo Leo´n Facultad de Medicina, Monterrey, NL, Mexico; 2Department of Pathology, West Virginia University, Morgantown, WV; 3Hologic, Marlborough, MA Study Objective: To evaluate whether concomitant Adiana hysteroscopic sterilization with NovaSure endometrial ablation can limit the ability to perform a three month post-operative hysterosalpingogram (HSG) with pathology tissue correlation. Design: Single site, open-label, prospective feasibility study. Setting: University medical center with on-site imaging and pathology capabilities. Patients: Twenty women who consented for bilateral Adiana matrix placement with subsequent NovaSure endometrial ablation approximately 90 days prior to undergoing a previously scheduled abdominal hysterectomy. Intervention: In accord with the Manufacturer’s Instructions For Use, bilateral placement of the Adiana silicone matrices was hysteroscopically performed using low-power radiofrequency ablation. Immediately after matrix placement, the endometrial cavity was ablated using the higherpowered NovaSure radiofrequency system. Subsequently, HSG was performed to assess tubal occlusion 90-105 days post-procedure. The patients then underwent a hysterectomy 1 - 2 days following their HSG. Measurements and Main Results: Ultrasound images of the intrauterine cavity were recorded immediately following the NovaSure procedure. In