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Outcome of hysteroscopic resection of submucous myomas for infertility
Vol. 64, No.4, October 1995
FERTILITY AND STERILITY Copyright c 1995 American Society for Reproductive Medicine
Printed on acid-free paper in U. S. A.
Outcome of hysteroscopic resection of submucous myomas for infertility
Mordechai Goldenberg, M.D. Eyal Sivan, M.D. Ziva Sharabi, M.D.
David Bider, M.D. Jaron Rabinovici, M.D. Daniel S. Seidman, M.D.*
Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Objective: To examine the reproductive outcome after operative hysteroscopic resection of submucous myomas in women for whom no other infertility factor was identified. Design: Fifteen infertile women with submucous myomas underwent an intensive workup to exclude other causes of infertility. Operative hysteroscopy for resection of the submucous myomas was performed using a rigid 26 French resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany). Setting: Academic tertiary referral center. Results: The mean ± SD duration of the procedure was 25.5 ± 5.6 minutes. No operative or postoperative complications occurred and all patients were discharged within 6 hours. The follow-up period was 12.0 ± 4.2 months (mean ± SD). Seven women conceived (pregnancy rate of 47%) and six of them subsequently delivered at term. Conclusion: The results of this study indicate that operative hysteroscopy achieved a pregnancy rate comparable to myomectomy via laparotomy. These results suggest that operative hysteroscopy is the procedure of choice for the resection of submucous myomas in infertile women. Fertil SteriI1995;64:714-6 Key Words: Submucous myomas, leiomyomas, hysteroscopy, myomectomy, operative hysteroscopic resection, pregnancy rate, reproductive outcome, infertility
Submucous myomas have been associated with infertility (1). These leiomyomas are seen with increasing frequency during the later reproductive years. Because childbearing commonly is delayed beyond the third decade oflife, myomas may present a growing medical problem in women attempting to conceive. In the past, the only surgical treatment available for submucous myomas was laparotomy and removal of the myoma by an incision through the myometrium. This procedure often disrupted the integrity of the uterine cavity. The successful outcome of such operations in infertile women has been established (2). Neuwirth and Amin have suggested that transcervical hysteroscopy may be the procedure of choice
for the diagnosis and treatment of submucous myomas (3). The immediate advantages ofthis procedure are apparent. The need for laparotomy is avoided as it is possible to remove the myoma without dissecting through the uterine wall. This results in reduced morbidity and eliminates the need for elective caesarian section at delivery. At present, there are few studies that report the reproductive outcome of operative hysteroscopy for removal of submucous myoma in infertile women (4). The aim of our study was to assess the pregnancy rate (PR) after hysteroscopic excision of submucous myomas performed in patients whose major cause for infertility was attributed to the myoma. MATERIALS AND METHODS
Received October 7, 1994; revised and accepted May 5, 1995. * Reprint requests: Daniel S. Seidman, M.D., Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel (FAX: 972-3-5352081). 714
Goldenberg et al. Hysteroscopic myomectomy
The study population included 15 patients attempting to conceive for > 2 years. These patients had been diagnosed as having a submucous myoma by office diagnostic hysteroscopy. All patients underFertility and Sterility
went a thorough investigation for infertility before surgery, including a hormonal evaluation, at least two semen analyses, a postcoital test, and a hysterosalpingogram. In cases in which tubal pathology was suspected based upon the hysterosalpigographic findings, a diagnostic laparoscopy also was performed. Women were included in the study group if the submucous myoma was the only identifiable cause for their infertility. Eight of the women complained of heavy menstrual bleeding. A preoperative transvaginal ultrasound (US) was performed in all cases to determine the size and location of the myomas. Only intracavitary submucous myomas were included in this study, as they were deemed the most appropriate for hysteroscopic removal. Preoperative GnRH analogues were not used. All women underwent myomectomy by operative hysteroscopy under general anesthesia. A rigid 26 French Myoma Resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany) was used for all procedures. The uterine cavity was distended for visualization using glycine 1.5% solution (Travanol Ltd., Ashdod, Israel). The glycine was flushed at a flow rate of 100 mUmin and a pressure of 110 to 150 mmHg with a Hamou Hysteromat (Karl Storz GmbH & Co.). Fluid balance was recorded by measuring the infused and drained fluid from the continuous flow hysteroscope, taking into account the fluid irrigated separately from the operative field into a collecting bag. The operation was monitored by video. None of the patients suffered from fluid overload (>2,000 mL) or electrolyte imbalance. The size of the submucosal myomas operated upon ranged from 3 to 6 cm. The sizes of the myomas were determined by preoperative US measurements and were supplemented clinically by comparing the myomas to the known size (0.7 cm) of the resectoscope cutting loop. Duration (mean::!: SD) of the procedure was 25.5 ::!: 5.6 minutes. Postoperative antibiotics or estrogens were not administered routinely. RESULTS
The mean::!: SD age of the 15 patients included in the study was 32.5 ::!: 4.2 years. Five patients suffered from primary infertility and 10 suffered from secondary infertility of ~2 years duration. Of those with secondary infertility, six had miscarried previously, four had undergone therapeutic abortion, and one had delivered before the detection of the submucosal myomas. All patients desired pregnancy. The mean::!: SD follow-up period was 12.0 ::!: 4.2 months (range 6 to 21 months). Seven of 15 patients conceived, 6 subsequently delivered at term and 1 has an ongoing pregnancy. The overall PR was 47%. Vol. 64, No.4, October 1995
There were no operative or postoperative complications in the present series. All patients were discharged within 6 hours of surgery. DISCUSSION
Leiomyomas of the uterus are the most common solid pelvic tumors. They occur in approximately 20% of women aged ~35 years (5). Because myomas arise most often during the third or fourth decade, they may have an important impact on reproductive performance. Submucous myomas may interfere with implantation of the fertilized ovum, by directly infringing upon the endometrial lining and by indirectly causing vascular compression and thereby curtailing blood flow (1). The submucous myomas also may cause a mechanical obstruction of the fallopian tubes, cervical canal, or uterine cavity (2). In addition, distortion of the uterine cavity may have an adverse effect on fertility by functioning as an intrauterine foreign body. Women suffering from submucosal myomas and infertility were treated in the past by myomectomy via laparotomy. The results of such operations have been reported in a number of studies (2, 6, 7). Garcia and Tureck (6) observed a PR of 47% in 17 women who had undergone abdominal myomectomy of a submucosal leiomyoma. Smith and Uhlir (7) similarly found a PR of 50% in 32 women after treatment by abdominal myomectomy for cases of myomas embedded at various sites in the uterus. Verkauf (2) recently reviewed the published reports assessing the outcome of abdominal myomectomy in infertile women. He noted that the value of myomectomy in treating infertility has been difficult to assess because uterine leiomyomata as an isolated potential contributory cause to infertility is uncommon. Of the studies reviewed in which women with no other apparent cause for infertility underwent abdominal myomectomy, the total PR was 58%. The length of follow-up in all series exceeded 10 months and the proportion of women who conceived within 1 year postoperatively was high. The reproductive outcomes after hysteroscopic myomectomy have been reported using a resectoscopic loop (8), yttrium aluminum garnet laser (9), or hysteroscopic scissors (10). These studies are summarized in Table 1. The results are somewhat better than those achieved by us. This fact may be attributed in part to a shorter follow-up period. Nevertheless, our results are comparable to those obtained after laparotomy (6, 7). We strongly recommend that US be performed as part of the preoperative workup to define the uterine myomas more precisely (11). Furthermore, office hysteroscopy should be carried out to distinguish beGoldenberg et al. Hysteroscopic myomectomy
715
I
I Table 1 Summary of Studies Reporting on the Reproductive Outcome After Hysteroscopic Myomectomy Author
No. of cases
Pregnancy rate*
Donnez et aI. (9) Valle (10) Carson and Brooks (8) Present study Total
24 16 13 15 68
16 (67) 10 (62) 10 (77) 7 (47) 43 (63)
Delivery rate* 16 8 8 6 38
(67) (50) (61) (40) (56)
* Values in parentheses are percentages.
tween a myoma and an endometrial polyp and to evaluate the size of the myoma and its relative protrusion into the endometrial cavity. It may be difficult to excise lesions that have a mural extension. However, in some cases, as the myoma is resected, the myometrium contracts pushing out the remaining myomatous tissue, thus allowing the surgeon to completely excise the myoma. Preoperative treatment with a GnRH analogue can be used in some instances to reduce the size of the myoma (12, 13), thus facilitating its surgical excision. Prophylactic postoperative estrogen therapy is advocated by some as a means for reducing the risk of adhesion formation. Our policy is not to administer estrogens on a routine basis. This is reserved for cases in which exceptionally large raw surfaces remain after removal of the myomas. The transabdominal procedure has been associated with prolonged time of anesthesia, increased blood loss and postoperative infection, a higher risk of postoperative adhesion formation, and the need for elective cesarean section at term (7). The postoperative complication rate is almost negligible when hysteroscopic removal of the myoma is performed. However, the use of the glycine distending media during operative hysteroscopy has been associated with hyponatremia (14, 15) and cerebral edema (16), as well as transient blood oxygen desaturation, hypercapnia, and coagulopathy (17). The shorter hospital stay, better patient convenience, and lower direct and indirect cost of the operative hysteroscopy should be taken into consideration as an additional advantage. All women in this study were discharged within 6 hours postoperatively. We conclude that hysteroscopic resection of submucosal myomas offers comparable results to
716
Goldenberg et aI. Hysteroscopic myomectomy
laparotomy in terms of reproductive outcome. Furthermore, the hysteroscopic procedure is more acceptable to the patients as it is associated with rapid recovery and little inconvenience. REFERENCES 1. Buttram VC, Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: 433-5. 2. VerkaufBS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992;58:1-15. 3. Neuwirth RS, Amin HK. Excision of submucous fibroids with hysteroscopic control. Am J Obstet Gynecol 1976; 126:95-9. 4. Corson SL. Operative hysteroscopy for infertility. Clin Obstet Gynecol 1992;35:229-41. 5. Wallach EE. Myomectomy. In: Thompson JD, Rock JA, editors. TeLinde's operative gynecology. 7th ed. Philadelphia: Lippincott, 1992:647-62. 6. Garcia C-R, Tureck RW. Submucosalleiomyomas and infertility. Fertil Steril 1984;42:16-9. 7. Smith DC, Uhlir JK. Myomectomy as a reproductive procedure. Am J Obstet GynecoI1990;162:1476-9. 8. Corson SL, Brooks PG. Resectoscopic myomectomy. Fertil SteriI1991;55:1041-4. 9. Donnez J, Gillerot S, Bourgonjon D, Clerckx F, Nisolle M. Neodymium:YAG laser hysteroscopy in large submucous fibroids. Fertil Steril 1990;54:999-1003. 10. Valle RF. Hysteroscopic removal of submucous leiomyomas. J Gynecol Surg 1990;6:89-96. 11. Fedele L, Bianchi S, Dorta M, Brioschi D, Zarotti F, Vercellini P. Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol 1991; 77:745-8. 12. Healy DL, Fraser HM, Lawson SL. Shrinkage of a uterine fibroid after subcutaneous infusion of a LHRH agonist. Br Med J 1984;289:1267-8. 13. Donnez J, Schrurs B, Gillerot S, Sandow J, Clerckx F. Treatment of uterine fibroids with implants of gonadotropin-releasing hormone agonist: assessment by hysterography. Fertil SteriI1989;51:947-50. 14. Istre 0, Skajaa K, Schjoensby AP, Forman A. Changes in serum electrolytes after transcervical resection of endometrium and submucous fibroids with the use of glycine 1.5% for uterine irrigation. Obstet Gynecol 1992;80:218-22. 15. Arieff AI, Ayus JC. Endometrial ablation complicated by fatal hyponatremic encephalopathy. JAmMed Assoc 1993;20: 1230-2. 16. Istre 0, Bjoennes J, N aess R, Hornbaek K, Forman A. Postoperative cerebral oedema after transcervical endometrial resection and uterine irrigation with 1.5% glycine. Lancet 1994;344:1187-9. 17. Goldenberg M, Zolti M, Seidman DS, Bider D, Mashiach S, Etchin A. Transient blood oxygen de saturation, hypercapnia, and coagulopathy after operative hysteroscopy with glycine used as the distending medium. Am J Obstet Gynecol 1994; 170:25-9.
Fertility and Sterility
FERTILITY AND STERILITY Copyright c 1995 American Society for Reproductive Medicine
Printed on acid-free paper in U. S. A.
Outcome of hysteroscopic resection of submucous myomas for infertility
Mordechai Goldenberg, M.D. Eyal Sivan, M.D. Ziva Sharabi, M.D.
David Bider, M.D. Jaron Rabinovici, M.D. Daniel S. Seidman, M.D.*
Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Objective: To examine the reproductive outcome after operative hysteroscopic resection of submucous myomas in women for whom no other infertility factor was identified. Design: Fifteen infertile women with submucous myomas underwent an intensive workup to exclude other causes of infertility. Operative hysteroscopy for resection of the submucous myomas was performed using a rigid 26 French resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany). Setting: Academic tertiary referral center. Results: The mean ± SD duration of the procedure was 25.5 ± 5.6 minutes. No operative or postoperative complications occurred and all patients were discharged within 6 hours. The follow-up period was 12.0 ± 4.2 months (mean ± SD). Seven women conceived (pregnancy rate of 47%) and six of them subsequently delivered at term. Conclusion: The results of this study indicate that operative hysteroscopy achieved a pregnancy rate comparable to myomectomy via laparotomy. These results suggest that operative hysteroscopy is the procedure of choice for the resection of submucous myomas in infertile women. Fertil SteriI1995;64:714-6 Key Words: Submucous myomas, leiomyomas, hysteroscopy, myomectomy, operative hysteroscopic resection, pregnancy rate, reproductive outcome, infertility
Submucous myomas have been associated with infertility (1). These leiomyomas are seen with increasing frequency during the later reproductive years. Because childbearing commonly is delayed beyond the third decade oflife, myomas may present a growing medical problem in women attempting to conceive. In the past, the only surgical treatment available for submucous myomas was laparotomy and removal of the myoma by an incision through the myometrium. This procedure often disrupted the integrity of the uterine cavity. The successful outcome of such operations in infertile women has been established (2). Neuwirth and Amin have suggested that transcervical hysteroscopy may be the procedure of choice
for the diagnosis and treatment of submucous myomas (3). The immediate advantages ofthis procedure are apparent. The need for laparotomy is avoided as it is possible to remove the myoma without dissecting through the uterine wall. This results in reduced morbidity and eliminates the need for elective caesarian section at delivery. At present, there are few studies that report the reproductive outcome of operative hysteroscopy for removal of submucous myoma in infertile women (4). The aim of our study was to assess the pregnancy rate (PR) after hysteroscopic excision of submucous myomas performed in patients whose major cause for infertility was attributed to the myoma. MATERIALS AND METHODS
Received October 7, 1994; revised and accepted May 5, 1995. * Reprint requests: Daniel S. Seidman, M.D., Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel (FAX: 972-3-5352081). 714
Goldenberg et al. Hysteroscopic myomectomy
The study population included 15 patients attempting to conceive for > 2 years. These patients had been diagnosed as having a submucous myoma by office diagnostic hysteroscopy. All patients underFertility and Sterility
went a thorough investigation for infertility before surgery, including a hormonal evaluation, at least two semen analyses, a postcoital test, and a hysterosalpingogram. In cases in which tubal pathology was suspected based upon the hysterosalpigographic findings, a diagnostic laparoscopy also was performed. Women were included in the study group if the submucous myoma was the only identifiable cause for their infertility. Eight of the women complained of heavy menstrual bleeding. A preoperative transvaginal ultrasound (US) was performed in all cases to determine the size and location of the myomas. Only intracavitary submucous myomas were included in this study, as they were deemed the most appropriate for hysteroscopic removal. Preoperative GnRH analogues were not used. All women underwent myomectomy by operative hysteroscopy under general anesthesia. A rigid 26 French Myoma Resectoscope (Karl Storz GmbH & Co., Tuttlingen, Germany) was used for all procedures. The uterine cavity was distended for visualization using glycine 1.5% solution (Travanol Ltd., Ashdod, Israel). The glycine was flushed at a flow rate of 100 mUmin and a pressure of 110 to 150 mmHg with a Hamou Hysteromat (Karl Storz GmbH & Co.). Fluid balance was recorded by measuring the infused and drained fluid from the continuous flow hysteroscope, taking into account the fluid irrigated separately from the operative field into a collecting bag. The operation was monitored by video. None of the patients suffered from fluid overload (>2,000 mL) or electrolyte imbalance. The size of the submucosal myomas operated upon ranged from 3 to 6 cm. The sizes of the myomas were determined by preoperative US measurements and were supplemented clinically by comparing the myomas to the known size (0.7 cm) of the resectoscope cutting loop. Duration (mean::!: SD) of the procedure was 25.5 ::!: 5.6 minutes. Postoperative antibiotics or estrogens were not administered routinely. RESULTS
The mean::!: SD age of the 15 patients included in the study was 32.5 ::!: 4.2 years. Five patients suffered from primary infertility and 10 suffered from secondary infertility of ~2 years duration. Of those with secondary infertility, six had miscarried previously, four had undergone therapeutic abortion, and one had delivered before the detection of the submucosal myomas. All patients desired pregnancy. The mean::!: SD follow-up period was 12.0 ::!: 4.2 months (range 6 to 21 months). Seven of 15 patients conceived, 6 subsequently delivered at term and 1 has an ongoing pregnancy. The overall PR was 47%. Vol. 64, No.4, October 1995
There were no operative or postoperative complications in the present series. All patients were discharged within 6 hours of surgery. DISCUSSION
Leiomyomas of the uterus are the most common solid pelvic tumors. They occur in approximately 20% of women aged ~35 years (5). Because myomas arise most often during the third or fourth decade, they may have an important impact on reproductive performance. Submucous myomas may interfere with implantation of the fertilized ovum, by directly infringing upon the endometrial lining and by indirectly causing vascular compression and thereby curtailing blood flow (1). The submucous myomas also may cause a mechanical obstruction of the fallopian tubes, cervical canal, or uterine cavity (2). In addition, distortion of the uterine cavity may have an adverse effect on fertility by functioning as an intrauterine foreign body. Women suffering from submucosal myomas and infertility were treated in the past by myomectomy via laparotomy. The results of such operations have been reported in a number of studies (2, 6, 7). Garcia and Tureck (6) observed a PR of 47% in 17 women who had undergone abdominal myomectomy of a submucosal leiomyoma. Smith and Uhlir (7) similarly found a PR of 50% in 32 women after treatment by abdominal myomectomy for cases of myomas embedded at various sites in the uterus. Verkauf (2) recently reviewed the published reports assessing the outcome of abdominal myomectomy in infertile women. He noted that the value of myomectomy in treating infertility has been difficult to assess because uterine leiomyomata as an isolated potential contributory cause to infertility is uncommon. Of the studies reviewed in which women with no other apparent cause for infertility underwent abdominal myomectomy, the total PR was 58%. The length of follow-up in all series exceeded 10 months and the proportion of women who conceived within 1 year postoperatively was high. The reproductive outcomes after hysteroscopic myomectomy have been reported using a resectoscopic loop (8), yttrium aluminum garnet laser (9), or hysteroscopic scissors (10). These studies are summarized in Table 1. The results are somewhat better than those achieved by us. This fact may be attributed in part to a shorter follow-up period. Nevertheless, our results are comparable to those obtained after laparotomy (6, 7). We strongly recommend that US be performed as part of the preoperative workup to define the uterine myomas more precisely (11). Furthermore, office hysteroscopy should be carried out to distinguish beGoldenberg et al. Hysteroscopic myomectomy
715
I
I Table 1 Summary of Studies Reporting on the Reproductive Outcome After Hysteroscopic Myomectomy Author
No. of cases
Pregnancy rate*
Donnez et aI. (9) Valle (10) Carson and Brooks (8) Present study Total
24 16 13 15 68
16 (67) 10 (62) 10 (77) 7 (47) 43 (63)
Delivery rate* 16 8 8 6 38
(67) (50) (61) (40) (56)
* Values in parentheses are percentages.
tween a myoma and an endometrial polyp and to evaluate the size of the myoma and its relative protrusion into the endometrial cavity. It may be difficult to excise lesions that have a mural extension. However, in some cases, as the myoma is resected, the myometrium contracts pushing out the remaining myomatous tissue, thus allowing the surgeon to completely excise the myoma. Preoperative treatment with a GnRH analogue can be used in some instances to reduce the size of the myoma (12, 13), thus facilitating its surgical excision. Prophylactic postoperative estrogen therapy is advocated by some as a means for reducing the risk of adhesion formation. Our policy is not to administer estrogens on a routine basis. This is reserved for cases in which exceptionally large raw surfaces remain after removal of the myomas. The transabdominal procedure has been associated with prolonged time of anesthesia, increased blood loss and postoperative infection, a higher risk of postoperative adhesion formation, and the need for elective cesarean section at term (7). The postoperative complication rate is almost negligible when hysteroscopic removal of the myoma is performed. However, the use of the glycine distending media during operative hysteroscopy has been associated with hyponatremia (14, 15) and cerebral edema (16), as well as transient blood oxygen desaturation, hypercapnia, and coagulopathy (17). The shorter hospital stay, better patient convenience, and lower direct and indirect cost of the operative hysteroscopy should be taken into consideration as an additional advantage. All women in this study were discharged within 6 hours postoperatively. We conclude that hysteroscopic resection of submucosal myomas offers comparable results to
716
Goldenberg et aI. Hysteroscopic myomectomy
laparotomy in terms of reproductive outcome. Furthermore, the hysteroscopic procedure is more acceptable to the patients as it is associated with rapid recovery and little inconvenience. REFERENCES 1. Buttram VC, Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: 433-5. 2. VerkaufBS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992;58:1-15. 3. Neuwirth RS, Amin HK. Excision of submucous fibroids with hysteroscopic control. Am J Obstet Gynecol 1976; 126:95-9. 4. Corson SL. Operative hysteroscopy for infertility. Clin Obstet Gynecol 1992;35:229-41. 5. Wallach EE. Myomectomy. In: Thompson JD, Rock JA, editors. TeLinde's operative gynecology. 7th ed. Philadelphia: Lippincott, 1992:647-62. 6. Garcia C-R, Tureck RW. Submucosalleiomyomas and infertility. Fertil Steril 1984;42:16-9. 7. Smith DC, Uhlir JK. Myomectomy as a reproductive procedure. Am J Obstet GynecoI1990;162:1476-9. 8. Corson SL, Brooks PG. Resectoscopic myomectomy. Fertil SteriI1991;55:1041-4. 9. Donnez J, Gillerot S, Bourgonjon D, Clerckx F, Nisolle M. Neodymium:YAG laser hysteroscopy in large submucous fibroids. Fertil Steril 1990;54:999-1003. 10. Valle RF. Hysteroscopic removal of submucous leiomyomas. J Gynecol Surg 1990;6:89-96. 11. Fedele L, Bianchi S, Dorta M, Brioschi D, Zarotti F, Vercellini P. Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol 1991; 77:745-8. 12. Healy DL, Fraser HM, Lawson SL. Shrinkage of a uterine fibroid after subcutaneous infusion of a LHRH agonist. Br Med J 1984;289:1267-8. 13. Donnez J, Schrurs B, Gillerot S, Sandow J, Clerckx F. Treatment of uterine fibroids with implants of gonadotropin-releasing hormone agonist: assessment by hysterography. Fertil SteriI1989;51:947-50. 14. Istre 0, Skajaa K, Schjoensby AP, Forman A. Changes in serum electrolytes after transcervical resection of endometrium and submucous fibroids with the use of glycine 1.5% for uterine irrigation. Obstet Gynecol 1992;80:218-22. 15. Arieff AI, Ayus JC. Endometrial ablation complicated by fatal hyponatremic encephalopathy. JAmMed Assoc 1993;20: 1230-2. 16. Istre 0, Bjoennes J, N aess R, Hornbaek K, Forman A. Postoperative cerebral oedema after transcervical endometrial resection and uterine irrigation with 1.5% glycine. Lancet 1994;344:1187-9. 17. Goldenberg M, Zolti M, Seidman DS, Bider D, Mashiach S, Etchin A. Transient blood oxygen de saturation, hypercapnia, and coagulopathy after operative hysteroscopy with glycine used as the distending medium. Am J Obstet Gynecol 1994; 170:25-9.
Fertility and Sterility