Diagnostic hysteroscopy in a procedure room setting compared to diagnostic hysteroscopy in the operating room

Background: To examine patients’ perceptions of and satisfaction with diagnostic hysteroscopy with endometrial biopsy in a procedure room/office setting as compared to diagnostic hysteroscopy with dilation and curettage (D&C) performed in the operating room (O.R.).Methods: This comparative quality improvement study contrasts diagnostic hysteroscopy with endometrial biopsy in a procedure room and diagnostic hysteroscopy with dilation and curettage in the operating room. 66 women participated in the study. Variables examined were: length of hospital stay, anesthesia and analgesia used, pain scores, recovery time, overall experience and satisfaction associated with the procedure.Results: The O.R. group spent on average an additional 2 hours and 21 minutes in hospital compared to the procedure room group. The procedure room group received local blocks without the presence of an anaesthetist whereas the O.R. group received a range of intravenous (I.V.) medications given by an anaesthetist in addition to a local block. There was a slight increase in perceived pain among the procedure room group immediately following the procedure. However, no difference was observed between the pain scores collected upon discharge. More women from the O.R. group missed work due to their procedure compared to those in the procedure room group. Those from the procedure room group were able to return to their normal activities much sooner than those in the O.R. group and all of them indicated that they would prefer the same location in the future. A quarter of the patients in the O.R. group would prefer to have it performed in the procedure room, instead of the OR in the futureConclusions: Diagnostic hysteroscopy is currently considered a valuable investigational tool for endometrial abnormalities and abnormal uterine bleeding. Most of these procedures can be performed in a procedure room setting without I.V. sedation or pre-operative narcotics. In our experience, a utero-sacral block using lidocaine is quite effective in controlling discomfort while passing various instruments through the internal cervical os. These techniques result in good visualization of the endometrial cavity, adequate and appropriate endometrial sampling with tolerable discomfort. The patients spend less time in the hospital, experience a much faster recovery and have less pre-operative restrictions

Hijama (wet cupping) for female infertility treatment: a pilot study

Background: To assess the effectiveness of wet cupping (Hijama) as a treatment of female factor infertility. The primary outcome measured was pregnancy rates after Hijama. The secondary outcome measured was the effect on the reproductive hormonal profile before and after Hijama.Methods: A pilot clinical study was conducted for the use of Hijama as treatment for female infertility at King Abdulaziz University Hospital from September 2013 to May 2015. Inclusion criteria included: patients with female factor infertility between 20-50 years of age. Exclusion criteria were women who were menopausal, male factor infertility and pregnancy. Informed consent was obtained from all patients. Upon inclusion in the study, an interview with the participant was done. Blood tests were done at the initial visit which included a complete blood count and hormonal profile (FSH, LH, Estradiol, Progesterone, TSH) if not done already. Patients had repeated Hijama each month if pregnancy did not occur.Results: Out of 59 women, 31 (52.5%) had primary infertility and 28 (47.5%) had secondary infertility. The duration of infertility ranged from 1 to 22 years. In 40 women (67.8%), the partner had a normal semen analysis and 19 (32.2%) had oligospermia. 12 women had an abnormal hystosalpngiogram (20.3%) with two women with complete bilateral tubal blockage. 36 women (61%) had a normal hormonal profile (FSH, LH, TSH, Prolactin). 12 patients (20.3%) became pregnant after hijama; 7 patients had only one or two sessions of Hijama and one patient had 7 sessions. Factors that were found to affect pregnancy rate included: patient with no dysmenorrhea (p 0.034), secondary infertility diagnosis (p 0.005) and history of OCP use (P 0.04). There were significant changes of the hormonal profile before and after Hijama.Conclusions: Hijama might be beneficial in infertile women to achieve a pregnancy. Further studies are needed to confirm the findings from this study

Do Multiple Attempts at Embryo Transfer Affect Clinical Pregnancy Rates?

Objective: During an in vitro fertilization treatment cycle, having embryos retained in the catheter after embryo transfer is a relatively uncommon and frustrating event. The reported incidence of retained embryos varies between 1% and 8%. It can be difficult to explain this unwanted event to patients. We wished to determine the incidence and the effect on pregnancy rates of having embryos retained in the transfer catheter, followed by immediate completion of transfer. Methods: We performed a retrospective chart review of all IVF cycles with embryos retained in the transfer catheter, followed by repeat transfer, between October 2009 and March 2012. We reviewed IVF cycles with or without ICSI, and included fresh and frozen embryo transfer cycles. All embryos were transferred on the third day after oocyte retrieval. Transabdominal ultrasound was used for guidance during the embryo transfer. Results: A total of 49 IVF treatment cycles with retained embryos that required re-transfer were identified. This represented 7.5% (49/652) of all IVF cycles with embryo transfer during that period. The clinical pregnancy rate in the repeat transfer group was 30.6% (15/49). The clinical pregnancy rate in all cycles in the same time period was 34.8% (227/652). These rates were not significantly different (P = 0.521). Conclusion: Having to re-transfer embryos retained in the transfer catheter does not have any significant effect on clinical pregnancy rates during IVF treatment cycles

Ureteric Injury During Transvaginal Ultrasound Guided Oocyte Retrieval

Background: Transvaginal ultrasound guided oocyte retrieval during in vitro fertilization is performed routinely around the world and has reduced the occurrence of intra-abdominal injury considerably over laparoscopic procedures. Despite this, injuries do occur. Case: We report a case of a 37-year-old patient who underwent IVF and encountered a ureteric injury during oocyte retrieval, which was recognized early and treated with ureteral stents with full resolution. During a subsequent IVF cycle, stenting of the ureters allowed better visualization, resulting in an uneventful retrieval and subsequent pregnancy. Conclusion: Ureteric injury can occur during transvaginal ultrasound guided egg retrieval. Prompt recognition is vital to successful treatment. Stenting of the ureters is the most common therapeutic modality and can be used in subsequent retrievals to identify the ureters

Long-term clinical outcomes of repeat hysteroscopic endometrial ablation after failed hysteroscopic endometrial ablation

The study aims to describe patient characteristics, uterine cavity shape and histopathology, complications, and long-term clinical outcomes of women who failed hysteroscopic rollerball or loop endometrial ablation (HEA) and subsequently consented to repeat hysteroscopic endometrial ablation (RHEA), and is a retrospective cohort study (Canadian Task Force classification II-2). The study was conducted in the university-affiliated teaching hospital. Patients included women who failed primary hysteroscopic endometrial ablation (PHEA, n = 183) and subsequently underwent RHEA by the senior author (GAV) from 1993 through 2007 with a minimum follow-up of 5 years. RHEA was performed under general anesthesia using 26 F (~9 mm) resectoscope, monopolar loop electrode in 136 (74.3 %), 3–5 mm rollerball in 41 (22.4 %) or combination in 6 (3.3 %) women. Patient characteristics, uterine cavity, and clinical outcomes of women who failed PHEA and subsequently consented to RHEA were evaluated by retrospective chart review and patient follow-up including office visits and/or telephone interview. The corresponding median age (range) for PHEA and RHEA was 40 (26–70) and 43 (29–76) years. Indications for PHEA included abnormal uterine bleeding (AUB, 52.7 %), AUB and dysmenorrhea (25.8 %), dysmenorrhea (18.8 %), and others (2.7 %). Indications for RHEA included persistent AUB (53 %), AUB and uterine/pelvic pain (26.2 %), uterine/pelvic pain only (19.1 %), postmenopausal bleeding (1.1 %), and thickened endometrium (0.5 %). Complications of RHEA (n = 7, 3.8 %) included false passage (3), uterine perforation (2), and bleeding (2). One patient with excessive bleeding required immediate hysterectomy. At a median follow-up of 9 years (5–19), 69 % of women avoided hysterectomy. Repeat hysteroscopic endometrial ablation is a feasible, safe, and long-term effective alternative to hysterectomy for abnormal uterine bleeding from benign causes when performed by experienced surgeons

Fertility and pregnancy outcomes following resectoscopic septum division with and without intrauterine balloon stenting: A randomized pilot study

BackgrounD AND OBJECTIVES: Although uterine stenting is performed routinely following hysteroscopic metroplasty, we were unable to find any evidence documenting its value with regards to septum reformation and/or obstetrical performance. To evaluate the benefits of intrauterine Foley catheter/balloon splinting after resectoscopic septum division on septum reformation, fertility, and pregnancy outcomes. Design AND SETTING: Prospective, randomized controlled pilot study (Canadian Task Force Classification I) conducted in university affiliated teaching hospital. Patients AND METHODS: Twenty-eight women with infertility and/or adverse pregnancy outcomes diagnosed with intrauterine septum were randomized into having a No. 14 pediatric Foley catheter/balloon for 5 days (n=13) vs. no balloon (n=15) following resectoscopic septum division. None of the patients received preoperative endometrial thinning, antibiotic prophylaxis or adjuvant postoperative hormone therapy. All uterine septa were divided under general anaesthesia using a 26 F (9 mm) resectoscope with a monopolar electrical knife using glycine irrigant solution (1.5%) and 120 watts of power of low voltage (cut) waveform. Results: The median age (range) was 29 years (23-38) and 32 years (22-40), respectively (P=.59). The groups were comparable by age, past obstetrical performance and comorbidities including endometriosis stage I-IV in 3 and 4 women, in the catheter/balloon and balloon group, respectively, and one in each group of polycystic ovarian syndrome and Crohn disease and one case of tubal obstruction in the balloon group. There were no intra- or postoperative complications. At 3 months, a hysterosalpingogram was done in 10 (77%) and 13 (87%) women, respectively, the results of which were normal. At 12-18 months, 1 woman in the balloon and 3 in the control group were not trying to conceive and 1 in each group had not conceived. Of the remaining women, 11 (92%) in each group had conceived and pregnancy outcomes included spontaneous abortion 3 (25%) and 4 (33.3%), ectopic pregnancy 0 and 1, second trimester loss 1 (8.3%) and 0 and term pregnancy 8 (66.6%) in both groups. Conception through assisted reproductive technology occurred in 2 and 1 woman, respectively. Conclusions: Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes

Diagnostic hysteroscopy in a procedure room setting compared to diagnostic hysteroscopy in the operating room

Background: To examine patients’ perceptions of and satisfaction with diagnostic hysteroscopy with endometrial biopsy in a procedure room/office setting as compared to diagnostic hysteroscopy with dilation and curettage (D&C) performed in the operating room (O.R.).Methods: This comparative quality improvement study contrasts diagnostic hysteroscopy with endometrial biopsy in a procedure room and diagnostic hysteroscopy with dilation and curettage in the operating room. 66 women participated in the study. Variables examined were: length of hospital stay, anesthesia and analgesia used, pain scores, recovery time, overall experience and satisfaction associated with the procedure.Results: The O.R. group spent on average an additional 2 hours and 21 minutes in hospital compared to the procedure room group. The procedure room group received local blocks without the presence of an anaesthetist whereas the O.R. group received a range of intravenous (I.V.) medications given by an anaesthetist in addition to a local block. There was a slight increase in perceived pain among the procedure room group immediately following the procedure. However, no difference was observed between the pain scores collected upon discharge. More women from the O.R. group missed work due to their procedure compared to those in the procedure room group. Those from the procedure room group were able to return to their normal activities much sooner than those in the O.R. group and all of them indicated that they would prefer the same location in the future. A quarter of the patients in the O.R. group would prefer to have it performed in the procedure room, instead of the OR in the futureConclusions: Diagnostic hysteroscopy is currently considered a valuable investigational tool for endometrial abnormalities and abnormal uterine bleeding. Most of these procedures can be performed in a procedure room setting without I.V. sedation or pre-operative narcotics. In our experience, a utero-sacral block using lidocaine is quite effective in controlling discomfort while passing various instruments through the internal cervical os. These techniques result in good visualization of the endometrial cavity, adequate and appropriate endometrial sampling with tolerable discomfort. The patients spend less time in the hospital, experience a much faster recovery and have less pre-operative restrictions

Hijama (wet cupping) for female infertility treatment: a pilot study

Background: To assess the effectiveness of wet cupping (Hijama) as a treatment of female factor infertility. The primary outcome measured was pregnancy rates after Hijama. The secondary outcome measured was the effect on the reproductive hormonal profile before and after Hijama.Methods: A pilot clinical study was conducted for the use of Hijama as treatment for female infertility at King Abdulaziz University Hospital from September 2013 to May 2015. Inclusion criteria included: patients with female factor infertility between 20-50 years of age. Exclusion criteria were women who were menopausal, male factor infertility and pregnancy. Informed consent was obtained from all patients. Upon inclusion in the study, an interview with the participant was done. Blood tests were done at the initial visit which included a complete blood count and hormonal profile (FSH, LH, Estradiol, Progesterone, TSH) if not done already. Patients had repeated Hijama each month if pregnancy did not occur.Results: Out of 59 women, 31 (52.5%) had primary infertility and 28 (47.5%) had secondary infertility. The duration of infertility ranged from 1 to 22 years. In 40 women (67.8%), the partner had a normal semen analysis and 19 (32.2%) had oligospermia. 12 women had an abnormal hystosalpngiogram (20.3%) with two women with complete bilateral tubal blockage. 36 women (61%) had a normal hormonal profile (FSH, LH, TSH, Prolactin). 12 patients (20.3%) became pregnant after hijama; 7 patients had only one or two sessions of Hijama and one patient had 7 sessions. Factors that were found to affect pregnancy rate included: patient with no dysmenorrhea (p 0.034), secondary infertility diagnosis (p 0.005) and history of OCP use (P 0.04). There were significant changes of the hormonal profile before and after Hijama.Conclusions: Hijama might be beneficial in infertile women to achieve a pregnancy. Further studies are needed to confirm the findings from this study

Do Multiple Attempts at Embryo Transfer Affect Clinical Pregnancy Rates?

Objective: During an in vitro fertilization treatment cycle, having embryos retained in the catheter after embryo transfer is a relatively uncommon and frustrating event. The reported incidence of retained embryos varies between 1% and 8%. It can be difficult to explain this unwanted event to patients. We wished to determine the incidence and the effect on pregnancy rates of having embryos retained in the transfer catheter, followed by immediate completion of transfer. Methods: We performed a retrospective chart review of all IVF cycles with embryos retained in the transfer catheter, followed by repeat transfer, between October 2009 and March 2012. We reviewed IVF cycles with or without ICSI, and included fresh and frozen embryo transfer cycles. All embryos were transferred on the third day after oocyte retrieval. Transabdominal ultrasound was used for guidance during the embryo transfer. Results: A total of 49 IVF treatment cycles with retained embryos that required re-transfer were identified. This represented 7.5% (49/652) of all IVF cycles with embryo transfer during that period. The clinical pregnancy rate in the repeat transfer group was 30.6% (15/49). The clinical pregnancy rate in all cycles in the same time period was 34.8% (227/652). These rates were not significantly different (P = 0.521). Conclusion: Having to re-transfer embryos retained in the transfer catheter does not have any significant effect on clinical pregnancy rates during IVF treatment cycles