Hysteroscopy newsletter vol 2 issue 1 english

Jan-Feb 2016 | vol. 2 | issue 1 www.hysteroscopy.info

WELCOME 1

Interview of the month 3

Step by Step 5

Highlights articles 8

What's your diagnosis? 10

Case Report 11

Devices 14

Hysteroscopy Basic 15

Tips and tricks 20

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Hysteroscopy has become an important tool to evaluate intrauterine pathology and it is starting to play a relevant role in sterility and in obstetrics.

I belive that diagnostic hysteroscopy is nowadays mandatory in unfertile women. In those patients the most common uterine pathology is fibroid and the best way to remove it is by minimally invasive treatment, as by hysteroscopy if fibroid is submucosal; when submucosal fibroid is removed, fertility rates usually increase, especially when is adopted the intracapsular myomectomy. Another pathology effectively treated by hysteroscopy is the uterine malformation. One of the malformations perfectly treated by hysteroscopy is the septate uterus, reducing the abortion rate. Than, the intrauterine adhesions, where hysteroscopy has been commonly used, particularly in Asherman syndrome, to improve fertility rates. Finally, uterine polyps are a common type of intrauterine pathology in unfertile women; when they have been removed by hysteroscopy, the fertility rates increase too.

On the other hand, the most current interest of hysteroscopy in obstetrics is on the post caesarian section uterine scar, that represent a new finding of the modern obstetrics, because is not present before the caesarian delivery topic. Hysteroscopy is used in the “caesarian scar syndrome” or “Morris syndrome” (abdominal pain, spotting and infertility).” Morris syndrome “need to be treated with hysteroscopy. The treatment consist in the deletion by operative hysteroscopy of the pathologic scar called isthmocele or “niche” in ultrasonography. This treatment reduces all symptoms and increase fertility rates in women affected by isthmocele. In facts, the niche removal probably can improve the spermatozoa function and their passing in the cervical canal.

Currently, operative hysteroscopy has been used in the conservative treatment of cervical pregnancy. This ectopic nontubal pregnancy (even called “distal ectopic pregnancy”) is a mortal obstetric pathology. In fact in 1954 a certain Artur Baptisti wrote: ”not many of you will be able to see a cervical pregnancy. The ones of you that will see that would have preferred to not have seen it”. The increase of the caesarian section rates all over the world produced more ectopic pregnancy, now also called “post caesarian section cervico-isthmic pregnancy”. Hysteroscopy has been indicated in the conservative treatment of such ectopic pregnancies, with the role to remove the pregnancy from the ectopic location in uterus.

Finally, hysteroscopy has been used also in association with laparoscopy, uterine artery embolization and metrotexate use.

As hysteroscopists, we have to find the limits of the hysteroscopy. Tools like Hysteroscopy Newsletter help to the gynecological community to a better knowledge of the Hysteroscopy.

HYSTEROSCOPY PICTURES

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INSIDE THIS ISSUE

Antonio Malvasi

TEAM COODINATORSPAIN

L. Alonso

EDITORIAL COMMITTEE

SPAINE. Cayuela

L. Nieto

ITALYG. Gubbini

A. S. Laganà

USAJ. CarugnoL. Bradley

MEXICOJ. Alanis-Fuentes

PORTUGALJ. Metello

ARGENTINA A. M. Gonzalez

VENEZUELAJ. Jimenez

SCIENTIFIC COMMITTEEA. Tinelli (ITA)A. Úbeda (Spa)A. Arias (Ven)

M. Rodrigo (Spa)A. Di Spiezio Sardo (Ita)

E. de la Blanca (Spa)A. Favilli (Ita)

M. Bigozzi (Arg)S. Haimovich (Spa)

R. Lasmar (Bra)A. Garcia (USA)N. Malhotra (Ind)

J. Dotto (Arg)I. Alkatout (Ger)

R. Manchanda (Ind)M. Medvediev (Ukr)

All rights reserved. The responsibility of the signed contributions is primarily of the authors and does not necessarily reflect the views of the editorial

or scientific committees.

HYSTEROSCOPY

PICTURES

www.hysteroscopy.info

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The concept of placental polyp (retained products of conception) refers to the presence of placental, or deciduous fetal remains, retained into the uterine cavity after an abortion, vaginal delivery or a cesarean section. It is estimated that occurs in about 1% of all births at term and likely to have a higher incidence in preterm births and abortions. Two theories have been proposed to explain the pathogenesis of this condition. One theory proposed by Eastman and Hellman suggest that the presence of retained products is probably due to a certain degree of placenta accreta. A second theory described by Ranney explains the retained products of conception due to differences in thickness, tone and contractility of the myometrium after injury during the current pregnancy. The treatment options used in the management of this condition include expectant management, medical and surgical option. Within the medical treatments, misoprostol is the most frequently used drug. Surgical options include blind sharp and suction curettage. Other alternatives include ultrasound guided trophoblastic tissue evacuation, and hysteroscopic removal under direct visualization with resectoscope which is currently considered a safe and effective surgical option.

If you are interested in sharing your cases or have a hysteroscopy image that you consider unique and want to share, send it to [email protected]

Jan-Feb 2016 | vol. 2 | issue 1

Detailed aspect of the chorionic villi

Hysteroscopy shows a soft tissue which bleeds easily

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INTERVIEW WITH... Dr. Stewart primary research interests are minimally invasive therapies for uterine fibroids and the genetics of uterine leiomyomas. Her clinical practice is devoted to uterine fibroid treatment in women who want future fertility and infertility diagnosis and treatment.

After more than 150 publications in different medias. What's your reflection about myomas? Myomas are much more complex and varied than we give them credit for.

To me it is like the 19th century concept of cancer: cancer is cancer and there is no need to understand the type. Only when you understood differences in prognosis and pathophysiology did it make sense to differentiate a thyroid cancer from a lymphoma and an ER+PR+ breast cancer from a triple negative one. I think because we’ve relied too much on hysterectomy, we consider all fibroids the same. I think in the next decade we will understand better the molecular subtypes of myomas and our current way of making decisions will seem pretty primitive.

Laser, miniresectoscopes, intrauterine morcellator, "cool loop" technique, pseudocapsula.... , are times changing in the "myoma world"? One of the great advances over the course of my career has been innovation in surgical equipment and technology. When I was an intern, Ob Gyn’s were doing laparoscopy and General Surgeons were not. So if a woman was seen in the emergency room with a question of PID vs. appendicitis, we would do the laparoscopy and if we saw a ruptured appendix they would do an open appendectomy. Ob Gyns are great surgical innovators and often ahead of their time. We are seeing this now with fibroids.

Is there a growing interest about myomas? There is a growing interest and I believe it is fueled by the increasing number of alternative to hysterectomy. When all you do is hysterectomies, myomas are much less interesting.

“ I think in the next decade we will understand better the

molecular subtypes of myomas..”

Elizabeth A. StewartProfessor of Obstetrics and Gynecology and Surgery

Mayo ClinicMinnesota U.S.A.

In this comprehensive and compassionate guide, Dr. Elizabeth A. Stewart helps women understand the treatment options now available.

Dr. Stewart encourages women with

fibroids to learn as much as they can before choosing a treatment plan. Providing the most reliable and up-to-date information on this very common and difficult disorder, she helps women understand uterine fibroids and make the best possible choices about their care.


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Has the debate about myomas and fertility finished or there are more things to know?

It has barely begun. I believe the genetic and biologic heterogeneity of fibroids makes some fibroids detrimental for fertility and others not. Thus one 3 centimeter FIGO type 3 fibroid may be very detrimental to fertility based on some factor it is secreting or storing and another one of the same size and location doesn’t play a role at all.

Do you think that the future treatment of leiomyomas will be only medical?

No, I think there will always be surgical therapy. It is hard to treat anything effectively when it is 10 centimeters or greater. However, I hope medical therapy will be able to be used for prevention and early intervention so we will see far fewer of these large fibroids.

You are also expert in adenomyosis. Do you think that this entity is usually underdiagnosed?

I do. Again, since we have few options other than hysterectomy people, don’t make the effort to establish its importance. I believe it accounts for more pelvic pain and heavy menstrual bleeding than we suspect. I also believe undiagnosed concomitant adenomyosis accounts for many failures of alternatives to hysterectomy for fibroids.

Do you have any advice for the Young fellow Who is beginning in the world of surgery?

Yes, develop your surgical skills by doing as many cases as you can. However, you also need to be able to walk away from those carefully honed skills and learn new techniques. You have to keep up with the times. When the general surgeons started doing laparoscopic cholecystectomies, the experts at open procedures who didn’t want to change got left behind.

“ I believe the genetic and biologic heterogeneity of fibroids

makes some fibroids detrimental for fertility and others not. ”

“Ob Gyns are great surgical innovators

and often ahead of their time.”



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In office hysteroscopyc polypectomy with bipolar electrode

M. R. Oña Lopez y C. García-Salmones GonzálezHospital Universitario Virgen de Valme. Sevilla. Spain

StepBy

Step

Endometrial polyps originate as focal hyperplasia of the basalis layer of the endometrium and become localized growths of endometrial tissue covered by epithelium containing therein a variable number of glands, stroma and blood vessels. They are usually benign, but 0.5-1% can become malignant. The diagnosis of endometrial polyps is more frequent due to the spread use of vaginal ultrasound. The highest incidence occurs between 40 and 65 years of age.

Polypectomy is indicated for any symptomatic endometrial polyp. Removal of asymptomatic polyps is also frequently recommended, but has not shown a significant benefit.

Hysteroscopy is a safe and effective method for resection of polyps under direct visualization. In recent years, the development of small caliber hysteroscopes as well as bipolar electrosurgical systems have allowed to perform most polypectomies in an office setting, in a procedure that is both diagnostic and therapeutic ("see and treat"). The average duration of outpatient polypectomy procedure ranges between 8 and 17 minutes with a reported success rate of 90-100%.

The main reason of failure of in office hysteroscopy are pain (which represent the most common cause of taking the patient to the operating room), the number and size of polyps, cervical stenosis, vasovagal syndrome, incomplete excision (provided that the test is well tolerated can be completed in a second procedure) and exceptionally bleeding that hinders adequate visualization.When performing in office hysteroscopy small caliber hysteroscopes (under 5 mm) are often used. Hysteroscopists generally lean towards the use of rigid hysteroscopes due to their better image resolution. Of these the one that we use the most is the continuous flow hysteroscope, with 2.8 mm optical with 30º angle lens, outer sheath of 4.5 to


Hysteroscopy Newsletter Hysteroscopy Newsletter Hysteroscopy Newsletter


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5.5 mm and a 5 Fr operative channel. The use of small gauge hysteroscopes such as Bettochi type allows to perform polypectomy in a less traumatic way as compared with the use of resectoscope. For in office hysteroscopic surgery it is essential to have hysteroscopic graspers, scissors and bipolar energy devices. The bipolar electrode (Versapoint® Gyrus®) allows vaporization, cutting and drying of the tissue under direct visualization.

PATIENT PREOP PREPARATION

It is advisable to inform the patient what to expect during the hysteroscopic procedure. She should be aware of cramping pain that is common during polypectomy caused by stimulation of the myometrium, which will facilitate patient cooperation during the procedure. In addition, to maintaining a dialogue with the patient during the procedure favors their distraction. The patient should be placed in lithotomy position, ensuring that the limbs are kept as separate as possible within their comfort. Her buttocks should surpass the edge of the table, in order to achieve any needed inclination of optics in cases of very anteflex uteri. When done in office setting, in premenopausal women is preferable to perform it during the early proliferative phase of the menstrual cycle. If performed during the late luteal phase, the endometrium is thickened with a polypoid appearance which may confuse the surgeon and hinder intervention. It may also be useful in cases of irregular menstrual bleeding to give the patient oral contraceptives to prime the endometrial lining. This may facilitate the procedure with a better view of polyps inside the uterine cavity, better visualization of the pedicle and decreased bleeding during the procedure. The administration of NSAIDs, with or without a mild sedative effect, 1 or 2 hours before the procedure, particularly anxious patients, is often indicated. Antibiotic prophylaxis is not indicated unless very special situations for bacterial endocarditis prophylaxis. In some patients the administration of intravaginal prostaglandins three hours before the procedure, could facilitate the insertion of the hysteroscope through the cervix; specially in those patients with increased risk of pain during the procedure due to cervical stenosis, elderly, uncontrollable anxiety, etc.

The anesthetic techniques most widely used are local infiltration of anesthetic for cervical and paracervical block. • For cervical infiltration inject 10-12 ml of anesthetic solution to 1 or 2% (lidocaine is the most used) over 6 points of the cervix. It is recommended to use a thin needle and 2 cm depth of penetration, being necessary to wait for 3-5 minutes to achieve total insensitivity of the cerix. • The paracervical block involves injecting the anesthetic solution around the nerve trunk, at a distance from the area to be anesthetized; the needle is placed at the posterior lip at 1.5 cm from the midline, on either side, exactly on the site of implantation of the uterosacral ligaments. The needle should penetrate no deeper than 2 cm, must inject 5-6 ml on each side, waiting for 3 or 4 minutes for effectiveness.



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SURGICAL PROCEDURE

Excision technique: The use of the bipolar electrode (Versapoint® Gyrus®): There is no need to place speculum or using tenaculum. The external os is located by vaginoscopy. Surgical brace type electrodes are generally used with setting at power of 50 W with intermediate cut (VC3) so much less bubbles are produced and is a painless procedure compare to using higher settings. In cases of polyps located at the uterine fundus or very large polyps in which it is anticipated that problems may be encountered to remove the polyp. It is recommended to cut the polyp in pieces before excising its base, because once the polyp excised from the uterine wall is very difficult to cut into smaller pieces which could cause a problem for the extraction of the polyp.

Extraction technique:

Fragments must be removed at the end of the procedure whenever possible to avoid inconvenience of multiple passages through the cervical canal in awake patients.Sometimes, due to a large size, is very difficult with remove the polyp using hysteroscopic graspers. In such cases is recommended to decrease the irrigation pressure at the time of extraction. If unable to remove, it can be left inside for expectant spontaneous expulsion of the polyp, provided that you have obtained enough tissue for pathologic analysis.

Complications:

Hysteroscopic polypectomy is a relatively safe procedure with only rare complications. The complication rate is 4-7 times less frequent than during hysteroscopic myomectomy. Pain: Although it is an invasive technique, only a fraction of patients describe the procedure as very painful. Generally, the greater discomfort occurs when passing the hysteroscope through the cervical canal especially in nulliparous and menopausal patients. Distension of the uterine cavity and electrical stimuli on the myometrium could cause discomfort specially when working on the base of the polyp. Bleeding complications: - Intraoperative: The first recommendation is to coagulate the bleeding surface with bipolar electrode in outpatient hysteroscopy - Postoperative: They are very rare, usually minor spotting not clinically relevant.



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HIGHLIGHT ARTICLESPublished on different medias

Accuracy of Hysteroscopic Endomyometrial Biopsy in Diagnosis of AdenomyosisDakhly DM, Abdel Moety GA, Saber W, Gad Allah SH, Hashem AT, Abdel Salam LO

J Minim Invasive Gynecol. 2015 Nov 12. [Epub ahead of print]

OBJECTIVES: To investigate the diagnostic accuracy of endomyometrial biopsy obtained via office hysteroscopy for the diagnosis of adenomyosis.(Cross-sectional study)PATIENTS: A total of 404 premenopausal women with symptoms clinically suggestive of having adenomyosis.INTERVENTIONS: All patients were subjected to 2-dimensional transvaginal sonography (TVS) in-office hysteroscopy examination with endomyometrial biopsy. Patients who subsequently underwent hysterectomy were included in the final analysis.MAIN MEASUREMENTS AND RESULTS: Accuracy of diagnostic modalities was represented using the terms sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy. A total of 292 patients were eligible for final analysis. Of these, 162 (55.47%) were diagnosed with adenomyosis based on hysterectomy specimens. TVS had a high sensitivity (83.95%) and a moderate specificity (60%). In contrast, endomyometrial biopsy was more specific (78.46%) than sensitive (54.32%). Hysteroscopic appearance of the endometrial cavity had low sensitivity (40.74%) and specificity (44.62%). Adding endomyometrial biopsy to TVS improved specificity (89.23%).CONCLUSION: Endomyometrial biopsy obtained via office hysteroscopy can diagnose adenomyosis with a high specificity and is recommended after TVS.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomaliesGrimbizis GF, Di Spiezio Sardo A, Saravelos SH, Gordts S, Exacoustos C, Van Schoubroeck D, Bermejo C, Amso NN,

Nargund G, Timmerman D, Athanasiadis A, Brucker S, De Angelis C, Gergolet M, Li TC, Tanos V, Tarlatzis B, Farquharson R, Gianaroli L, Campo R.

Hum Reprod. 2016 Jan;31(1):2-7.

STUDY QUESTION: What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system?SUMMARY ANSWER: The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented.STUDY DESIGN, SIZE, DURATION: The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project.PARTICIPANTS/MATERIALS, SETTING, METHODS: The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method.MAIN RESULTS AND THE ROLE OF CHANCE: Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically.



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DID YOU KNOW...?

Metaplasia, defined as transformation of a well differentiated tissue into another type of well differentiated tissue is rarely found in the endometrium with only a few cases reported in the literature; being

bone metaplasia the most common.

Very often endometrial polyps are diagnosed as an incidental finding during an infertility work up. They are present in up to 25%

of hysteroscopies in patients with infertility of unknown origin.



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Sometimes, when performing hysteroscopy, it is important to pay attention to every corner of the uterus, as Vasari stated «cerca trova», «he who

seeks finds»

WHAT'S YOUR DIAGNOSIS?

Answer to the previous issue: Endometrial cystic atrophy induced by tamoxifen

HysteroscopyState of the Art

O. R. Kochli2000; 194 pages

This comprehensive textbook covers all the important aspects of hysteroscopy: pre- and postoperative hormonal treatment in patients with hysteroscopic surgery; hysteroscopy in infertility - diagnosis and treatment including falloposcopy; differentiation and management of endometrium abnormalities and leiomyomas by hydrosonography; hysteroscopic resection of submucous myomas; diagnostic hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal patients, and hysteroscopy in the assessment of postmenopausal bleeding. Furthermore, hysteroscopy and adenomyosis, tamoxifen-induced abnormalities and the diagnosis of endometrial cancer and its precursors are highlighted.


Hysteroscopy Newsletter


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CASE REPORTEndometrial cancer and its relation with cupper T IUD.

Case ReportJ. Alanis-Fuentes, Dra. Abigail Viveros Gallardo, Dra. Cindy Paola Morataya Ortiz.

H. Dr. Manuel Gea González. Mexico

The patient is a 34 y/o G3P2012 with morbid obesity (BMI: 44.6) unremarkable medical history. Patient reports regular menstrual bleeding with mild to moderate menstrual flow. Denies use of hormonal contraception. Patient reports having a Cupper T IUD inserted 6 years ago. She requested IUD removal. In office IUD removal was unsuccessfully attempted in the office due to inability to visualize the strings. A pelvic XR revealed the presence of the IUD in the pelvis. In office hysteroscopy was performed with the findings of the left arm of the IUD embedded in the left uterine wall and a solid 2x2 cm solid mass at the fundus with irregular borders with small satellites excrescences, with atypical vascularization; the tumor is located on an atrophic endometrial surface, directed biopsy is taken revealing endometrioid type endometrial adenocarcinoma.

DISCUSSION: Currently about 180 million women worldwide use intrauterine contraceptives. Intrauterine device (IUD) is a highly effective long acting reversible contraceptive with a failure rate of 0.5 to 0.8%. The copper IUD TCu 380 A, is one of the most widely used in North America, is made of polyethylene with a T-shape, the active component is 380 mm2 of surface copper wire exposed, which is wound in the vertical arm of the device (stem), also contains copper coils in the horizontal arms. The distal end of the shaft terminates in a ball of 3 mm through which a polyethylene monofilament is tied with two white yarns, which are used for detection and traction. The frame IUD contains radiopaque barium sulfate. (1) After IUD insertion, an inflammatory response that induces the production of tumor necrosis factor alpha (TNF-α) by the cells of the endometrial glands is generated; as a result, the embryo implantation rate is decreased. (2) Copper concentrations in the cervical mucus; affect the motility and viability of sperm. The IUD creates a toxic inflammatory response to the presence of sperm and also increases the presence of leukocytes in the endometrial cavity, which decreases fertilization by destroying sperm. Toxic ions that kill sperm and can even affect the ovaries are also generated. (3)


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The described proinflammatory reaction and toxic long-term use of the cupper IUD may be associated endometrial cancer and the association of contraception and cancer has been the subject of analysis in several studies. Tsogzolmaa et al, conducted a prospective study in Shanghai, China, from 1996 to 2006, with a cohort of 66.661 Chinese women, of which 76.7% had used contraception for at least 7.5 years. A total of 2,250 women were diagnosed with cancer. The use of contraception (oral contraceptives, intrauterine devices or tubal sterilization) was associated with an increased risk of rectal and gallbladder cancer, and a reduced the risk of thyroid, breast and lung cancer. Having a tubal sterilization was associated with increased risk of uterine cancer and decreased risk of gastric cancer. (4)

Many epidemiological studies have linked the use of the intrauterine device with decreased risk of endometrial cancer. Tao MH, et al in China, studied 1204 patients with newly diagnosed endometrial cancer, compared with a cohort of 1212 healthy patients. Patients who developed endometrial cancer (485) had used IUDs for more than years, compared to 687 patients in the control group. (5)

It is speculated that the reduction in endometrial cancer in patients with IUD is related to inhibition of the binding of estrogen and progesterone to the endometrial receptors, decreasing the concentration of receptor the number of nuclear endometrial cells, these changes can influence the activity of estrogen and progesterone which has protective effect at the level of the endometrium. (6)

Continued use of TCu intrauterine device, after 6 months, induces a significant reduction in the mitotic index of endometrial cells, as well as reducing the concentration of estrogen receptors, but does not affect the levels of serum progesterone, estradiol or the concentrations of progesterone receptors, which could interfere with the protective effect of copper IUD in endometrial cancer. (7) Other factors such as obesity, ethnicity, specially Hispanic or African American race, low socioeconomic status and / or the presence of chronic degenerative disease, play a crucial and defining role in the development of endometrial cancer. Of note, all these are modifiable factors, and 40% of obese women with endometrial cancer or endometrial hyperplasia, know that obesity is the determining factor for the development of this disease. (8)

Watch the full video on medtube

BIBLIOGRAFIA:1-Fritz MA., Speroff L., Endocrinología ginecología clínica y esterilidad, 8ª edición en español, 2011, Philadelphia, USA. págs.: 1095-1119

2- Chou CH., et al. Divergent endometrial inflammatory cytokine expression at periplantation period and after the stimulation by copper intrauterine device. Sci Rep. 2015 Oct 15;5:15157.

3-Sivin I., et al. State-of-the-art of non-hormonal methods of contraception: III. Intrauterine devices. Eur J Contracept Reprod Health Care. 2010 Apr;15(2):96-112.

4-Dorjgochoo T., et al. Use of oral contraceptives, intrauterine devices and tubal sterilization and cancer risk in a large prospective study, from 1996 to 2006. Int J.2009 May 15;124(10):2442-9.

5-Tao MH, et al. Oral contraceptive and IUD use and endometrial cancer: a population-based case-control study in Shanghai, China. Int J Cancer. 2006 Nov 1;119(9):2142-7.

6-Parazzini F., et al. Intrauterine device use and risk of endometrial cancer. Br J.1994 Oct;70(4):672-3.

7-Guleria K., et al. Evaluation of endometrial steroid receptors and cell mitotic activity in women using copper intrauterine device: Can Cu-T prevent endometrial cancer? J Obstet Gynaecol Res. 2004 Jun;30(3):181-7.

8-Beavis AL., et al. Almost half of women with endometrial cancer or hyperplasia do not know that obesity affects their cancer risk. Gynecol Oncol Rep. 2015 Jul 8;13:71-5.


https://medtube.net/gynecology/medical-videos/16959-iud-and-endometrial-cancer

https://medtube.net/gynecology/medical-videos/16959-iud-and-endometrial-cancer

http://www.ncbi.nlm.nih.gov/pubmed/?term=Chou%20CH%5BAuthor%5D&cauthor=true&cauthor_uid=26469146

http://www.ncbi.nlm.nih.gov/pubmed/?term=Divergent+endometrial+inflammatory+cytokine+expression+at+peri-implantation+period+and+after+the+stimulation+by+copper+intrauterine+device

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sivin%20I%5BAuthor%5D&cauthor=true&cauthor_uid=20230337

http://www.ncbi.nlm.nih.gov/pubmed/?term=April%202010;15:96%E2%80%93112

http://www.ncbi.nlm.nih.gov/pubmed/19170208





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CongresSINTERNATIONAL

59th All India Congress of Obstetrics & GynaecologyAgra, India |Jan 13-17|2016

World Congress on recurrent pregnancy lossCannes, Francia |Jan 14-17|2016

The 23rd World Congress on Controversies in Obstetrics, Gynecology & Infertility Melbourne, Australia |Mar 21-23|2016

44th AAGL Global Congress of Minimally Invasive Gynecology Dubai,EAU |Mar 27-29|2016

14th ESC Congress / 2nd Global ESC ConferenceBasel, Switzerland |May 4-7|2016

The 20th Ain Shams Obstetrics and Gynecology International Conference (ASOGIC). Cairo, Egypt |May 25-26 |2016

ISGE 25th Annual Congress & 4th Croatian Congress on MIGSOpatija, Croatia |May 25-28 |2016

4th International Congress of Gynaecology and ObstetricsBarcelona,Spain |May 28-30|2016

ESHRE 32nd Annual Meeting Helsinki, Finland |Jul 3-6 |2016

12th AAGL International Congress on Minimally Invasive Gynecology Mumbai, India |Jun 2-5 |2016

RCOG world congress 2016 Birmingham, UK |Jun 20-22|2016

ESGE 25th Annual Congress Brussels, Belgium |Oct 2-5 |2016


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HYSTEROSCOPY

DEVICESModified Novy

Intended for use through the operating channel of a hysteroscope or other uterine access device for hysteroscopic or fluoroscopic selective catheterization and cannulation of the proximal fallopian tube(s). This may be followed by the

introduction of chromotubation solution or contrast medium to evaluate tubal patency. The wire guide in the Modified Novy Cornual Cannulation Set is intended only to facilitate placement of the inner catheter.

The Novy is not intended for complete catheterization of the fallopian tube(s)or tubal recanalization. Also, it is not intended for embryo transfer or other assisted

reproduction procedures.

Proximal tubal disease: the place for tubal cannulation.Das S, Ardo LG, Seif MW

Reprod Biomed Online. 2007 Oct;15(4): 383-8

Tubal disease is the cause of subfertility in approximately 30% of women, and 10–25% of these are due to proximal tubal obstruction. False-positive diagnosis of proximal tubal obstruction can be as high as 50%. A decrease in expertise in tubal

microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF. Tubal cannulation can be used effectively to restore

patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques. This review examines the evidence supporting the effectiveness of tubal cannulation and aims to enhance

awareness of the procedure as an option for the management of female subfertility secondary to isolated proximal tubal obstruction.

The National Institute for Health and Clinical Excellence (NICE) guideline for the management of infertility in secondary care(2004) has recommended tubal cannulation as a treatment option in cases of proximal tubal occlusion.


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HYSTEROSCOPYBASIC


ENDOMETRIAL CYCLE M. Rodrigo. Centro Gutenberg. Spain

The endometrium has the ability to experience cyclical changes in response to different hormonal stimuli that occur during the menstrual cycle. These changes are known as the endometrial cycle. The endometrial cycle is divided into three phases: the proliferative phase, the secretory phase and the menstrual phase.

1- The proliferative phase: starting from the end of the menstrual period to ovulation, ie, between the 4th to 14th day of the cycle. During this phase, egg development occurs and is mainly mediated by estrogen. The endometrium reaches a thickness of 1-3 mm. During this phase the endometrial lining grows due to development of the endometrial glands, the stroma and the vascular component.

2- The secretory phase: also known as the luteal phase begins at the time of ovulation up to menstruation, ie between the 14th to 28th days of the cycle. It is this phase the corpus luteum produces high levels of estrogen and progesterone. The endometrium reaches 5-6 mm thickness. The glands have some morphological changes and secretory activity becoming more tortuous and dilated. The endometrial spiral arteries are also developed.

3- The menstrual phase: in the absence of pregnancy, a sudden decline of estrogen and progesterone production by the corpus luteum produces endometrial ischemia due to vasoconstriction of the spiral arteries between 1 to 24 hours before menstruation. After the period of vasoconstriction there is return of blood flow to the superficial layers of the endometrium, resulting in detachment only of the basal layer. During this phase, uterine contractions occur to facilitate the expulsion of endometrial tissue.




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Adapted from: Tratado y Atlas de histeroscopia. R. Labastida

These changes occurring during the endometrial cycle, give the endometrium different hysteroscopic patterns typical of each phase, allowing the assessment of normal “hysteroscopic” endometrial cycle.

1- Proliferative phase: the endometrium has a light pink color due to the presence of small vessels. The surface is smooth and glands are small and rounded, appearing as small and uniform dots. The endometrial notch is small and generally hemorrhagic.

2- Secretory phase: The endometrium has a pale pink color. The surface is slightly wavy and irregular. The glands are larger, open and rose at the level of the superficial layer. The vessels disappear from the endometrial surface due to stromal edema. The endometrium reaches its maximum thickness at this stage, showing a deep avascular endometrial notch.

3- Menstrual phase: the endometrium takes on a reddish color, with indentations and bleeding. In this phase there are alternating areas of detaching and well preserved endometrium.

Proliferative phase

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Partnership agreement between Hysteroscopy Newsletter and Medtube

MEDtube is an online video-centric education and communication Platform for Healthcare Professionals. The innovative website was launched in 2009 by two visionary surgeons. The idea was based on their own clinical practice. MEDtube.net was brought online in July 2011.

MEDtube is now the world's largest online repository with high-quality multimedia content of clear practical and educational value, counting over 14,000 professional medical videos. The resources are shared by physicians, clinicists, medical societies and universities. MEDtube community (over 100,000 registered HCPs) contribute to the idea of sharing medical knowledge. MEDtube is free to use by the community of professionals (registration is required).

The e-library contains medical videos, surgical videos, photos of medical cases, visualizations and animations, interviews, presentations, webcasts, case-reports and other professional materials in all medical Specialties. MEDtube is also broadcasting live surgery events across the world. The global community of Professionals may educate from resources provided on MEDtube.net and to benefit from the large community of colleague doctors, increasing their professional skills and improving quality of their work with patients.

MEDtube is dedicated to Healthcare Professionals

(i.e. MDs, medicine students, university

teachers, assistants) and all the content is

available to registered users without limitations and free of charge. Each

piece of content has been assigned by

different level of access and some of it is

available only to pre-defined groups of

Specialists. No fees are charged for public

demonstration of the content available on

MEDtube and you are welcome to utilise

MEDtube webpage for such purpose (eg. during

lectures). The registration provides users with additional services and benefits from the MEDtube

community.

Contact:If you are interested in

publish any hysteroscopic video,

please contact [email protected]


mailto:[email protected]

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Hysteroscopy ConundrumsChronic endometritis

Prevalence of chronic endometritis in repeated unexplained implantation failureIn his last article, E. Cicinelli suggests that chronic endometritis was identified in 30.3% of patients with repeated implantation failure at IVF and women diagnosed with CE had lower implantation rates (11.5%) after IVF cycles Do you usually look for endometrial micropolyps when you perform a diagnostic hysteroscopy?

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TIPS and TRICKS... 4U

Some things just can’t be learned from books. Some things can only be learned through experience. In this section the best hysteroscopists will share their tricks with you.

When confronted with a stenotic cervix while performing in office hysteroscopy, we offer various alternatives that facilitates the access to the uterine cavity, which depend on the location and consistency of the cervical tissue adhesions.

1- Input optical rotation technique: Rigid optics have a bevel tip, which gives the capacity for tissue penetration and ability to separate the fibers. Most cases of cervical stenosis are solved by a rotational movement of the tip of hysteroscope to separate the fibrous tissue and allow to advance of the hysteroscope.

2- Mechanical entry: The use of biopsy forceps or hysteroscopic scissors help to overcome more severe cases that are not solved by the input optical rotation technique. The introduction of scissors or a closed clamp into the stenotic cervical canal and subsequent opened extraction, dilate the cervix just enough to introduce the tip of the hysteroscope. Sometimes the use of scissors is needed to cut the lateral corner of the cervical canal or fibrous tissue adhesions at the level of the internal os.

3- Entrance with bipolar electrode: The use of a bipolar electrode allows the section of the ring fibers of the cervix, extending the cervical os allowing the passage of the hysteroscope. These sections should be done at the level of the side edges of the cervical os.

4- Dilation with stems: There is evidence describing that the inyection of a dilute solution of vasopressin (0.05 U/mL) at the cervical stroma, significantly reduce the force needed to dilate the cervix. This technique could be an alternative when faced with a stenotic cervix in a patient that has not received pre-procedure prostaglanding to prime the cervix.


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IMAGE 4

TALKING ABOUTHow to train in hysteroscopy in modern gynecology?

M. Bigozzi. Md. PhD. Buenos Aires. Argentina

Hysteroscopy is a worldwide widely performed procedure, being endometrial pathology a highly prevalent disease in all age groups, it is extremely important for the gynecologist in training to master the skills of performing both diagnostic and operative hysteroscopy as well as the clinical management of uterine pathology. This knowledge is slowly obtained during training. We believe hysteroscopy training should start during residency. It should start by getting familiar with the hysteroscopic images of the different pathologies followed by learning how to operate and handle the instruments.

There are a wide variety of workshops that are being offered worldwide by very experienced hysteroscopists, many of them with hands on experience opportunity. We strongly recommend enrolling in these courses because the learning should be a dynamic progress with constant improvement. As we can see, also reflected in work published in previous issues of this Newsletter, there are always emerging new techniques and new indications for the use of hysteroscopy. Thus, we see that the limit of hysteroscopy is constantly moving. To keep yourself up to date it is important to attend to hysteroscopy courses and workshops where “Masters in the Field” share their knowledge and give away tricks to convey the techniques with greater ease and efficiency. Also, in recent years, virtual simulators have acquired great role in training, the use of dry and computer models as well as animal models help in the training and creation of new techniques. Like in any other procedure, practice and experience as well as a solid knowledge background will allow the gynecologist to perform an adequate hysteroscopy to achieve the correct diagnosis and to offer accurate treatment.



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HYSTEROSCOPY

Editorial teaMHysteroscopy Newsletter is an opened forum to all professionals who

want to contribute with their knowledge and

even share their doubts with a word-wide

gynecological community

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HYSTEROscopy group


Dear friends,

The New Year just hit us; in a blink of an eye we are welcoming 2016 and the old 2015 is gone. I look back and see a very productive year. This past year our precious Newsletter was born. It has not being easy, after much work, mistakes, networking and precious contribution from world leaders we managed to produce 6 robust bimonthly issues. We all have an unspoken agreement, which is to make every issue better than the previous one. I proudly say that we have reached that goal. But with the beginning of a New Year, its time to set new goals and resolutions. Some of us will try to exercise more, eat healthier, and spend more time with our families. We, the members of the editorial team of Hysteroscopy Newsletter, have an extra New Year resolution, which is to continue to fight, actually to fight harder, and to bring hysteroscopy to a new level. The fight is not easy, for some unknown reason, hysteroscopy; a technique that should be widely available, is indubitable underutilized.

We recently witnessed how without solid evidence, hysteroscopic tubal occlusion is now being discouraged, just to name one. But with our advocacy we hope that the use of hysteroscopy will not only increase in the years to come, giving hysteroscopy its well-deserved role in modern gynecology. We will focus on bringing most of the hysteroscopic procedures into the office and get them out of the operating rooms. We are committed to share our knowledge, to give you precious tips and tricks, bringing the evidence to you. At the same time, we welcome your contributions and encourage you to share with us your experiences. We will continue to do this having one main goal, which is helping our patients providing minimally invasive surgical options.

The time has come, lets make of 2016 a wonderful year. To all of you…. Happy New Year!

Jose “Tony” Carugno Assistant Professor Obstetrics and Gynecology University of Miami.Jackson Memorial. Miami. USA


Documents

Hysteroscopy newsletter vol 2 issue 1 english