(Ex. Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
Hysteroscopy has been used extensively for the management of a number of intrauterine conditions. There is a new trend towards hysteroscopic resection of the lateral endometrium and myometrium to expand the uterine cavity in cases of infertility. Two such cases with catastrophic results are presented.
Hysteroscopy is useful in evaluation of infertility, abnormal uterine bleeding, repeated pregnancy wastage, suspected endometrial tuberculosis, endometrial carcinoma and hypomenorrhea.[1-5] It is used extensively for the management of conditions like submucosal leiomyomas, endometrial polyps, uterine septum, removal of intrauterine devices whose threads are missing, and Asherman syndrome.
[6-11] There is a new worrying trend towards hysteroscopic resection of the lateral endometrium and myometrium to expand the uterine cavity in cases of infertility. Two such cases with catastrophic results are presented.
Case Report 1
A 26 year old infertile woman presented to our outpatient clinic for evaluation of her infertility. She had been married for five years, had been cohabiting since then and had not used any contraception. Her menarche had been at the age of 12 years. Her past cycles had been every 28-30 days, regular, mildly painful and with moderate flow. She had hypomenorrhea for 1 year, from the time of her hysteroscopic surgery. She had undergone a laparoscopy plus hysteroscopy for evaluation of infertility. Her laparoscopic and hysteroscopic findings had been reported as normal. Hysteroscopic resection of the lateral endometrium and myometrium had been done at that time. She did not have any significant medical or surgical disease. Findings of her general and systemic examination were normal. Gynecological examination showed a normal sized, mobile uterus and normal vagina. There were no abdominal or pelvic masses. Her investigations like hemogram, urinalysis, plasma sugar levels (fasting and postprandial), liver function tests, renal function tests, thyroid function tests, electrocardiogram, chest radiograph and serological tests for syphilis, HIV, hepatitis B and hepatitis C yielded normal results. Follicular study showed that she was ovulating normally. Her husband’s semen analysis showed normal findings. Laparoscopy and hysteroscopy were performed. Laparoscopy showed normal uterus, fallopian tubes, ovaries, pelvic peritoneum and intraabdominal structures. Hysteroscopy showed occlusion of endometrial cavity with extensive fibrosis, such that there was a central tubular canal and non-visualization of the tubal ostia (figure 1).
Case Report 2
A 27 year old infertile woman presented to our outpatient clinic for evaluation of her infertility. She had been married for seven years, had been cohabiting since then and had not used any contraception except during the first year after marriage. Her menarche had been at the age of 13 years. Her past cycles had been every 30 days, regular, mildly painful and with moderate flow. She had hypomenorrhea for 2 year, from the time of her hysteroscopic surgery. She had undergone a laparoscopic myomectomy 3 years ago. She had also undergone a hysteroscopy for evaluation of infertility. Her hysterosalpingography prior to the hysteroscopy showed normal findings. Her hysteroscopic findings had been reported as normal, except the presence of a uterine septum. Hysteroscopic resection of the septum, lateral endometrium and myometrium had been done at that time. She did not have any significant medical or surgical disease. Findings of her general and systemic examination were normal. Gynecological examination showed a normal sized, mobile uterus and normal vagina. There were no abdominal or pelvic masses. Her investigations like hemogram, urinalysis, plasma sugar levels (fasting and postprandial), liver function tests, renal function tests, thyroid function tests and serological tests for syphilis, HIV, hepatitis B and hepatitis C yielded normal results. Follicular study showed that she was ovulating normally. Her husband’s semen analysis showed normal findings. Laparoscopy and hysteroscopy were performed. Hysteroscopy showed Asherman syndrome, there being fibrous bands passing across the uterine cavity, occlusion of the left one-fourth of the uterine cavity by fibrous tissue, and extensive fibrosis in the fundus and along the right uterine wall (figure 2). Laparoscopy showed a few adhesions between the back of the uterus and omentum. The fallopian tubes were thickened. The right tube was patent on chromopertubation, while the left tube was blocked. The ovaries were normal.
Indications for operative hysteroscopy considered to be useful include endometrial ablation for abnormal uterine bleeding, lysis of intrauterine synechiae of Asherman syndrome, resection of uterine septum, endometrial polyps and leiomyomas. There have been reports of resection of uterine walls for the management of hypoplastic uterus and T-shaped uterine cavity, the value of which is logically questionable and has not been proved by clinical studies.[12-15] The value of such procedures has prior to in vitro fertilization has also not been proved.
There has been a worrying trend towards performing lateral endometrial and myometrial resection of women undergoing evaluation for infertility and to be subjected to in vitro fertilization and embryo transfer. No studies have been published so far on these methods and their results. We encounter some women who have undergone this procedure elsewhere and have reported to us for management when they did not get pregnant. The two cases presented here presented in a span of one month, prompting us to report them.
Hysteroscopic resection of endometrium, leiomyomas and septa can cause serious complications, including Asherman syndrome.[17,18] Hence it makes sense to perform the procedure only when its value has been proved for the indication for which it is performed. It is also dangerous when it is performed when it is not warranted. Furthermore, lateral resection of the myometrium for infertility or circumferential resection of the myometrium for hypoplastic uterus reduce the myometrial thickness. Such uteri are likely to rupture should the patient manage to get pregnant and reach the third trimester.
Unwarranted hysteroscopic resection of the lateral endometrium and myometrium should not be performed for the management of infertility.
I thank Dr Aashlesha Kulkarni for taking operative photographs.
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Parulekar SV. Hysteroscopic Lateral Myometrial Resection – A Procedure To Be Shunned? JPGO 2019. Volume 5 Number 8. Available from: https://www.jpgo.org/2019/08/hysteroscopic-lateral-myometrial.html