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48
Fig. 5.4 Saline infusion sonohysterogram demonstrating intrauterine adhesive disease. Note that the uterine cavity
does not distend uniformly with saline in these cases
J. Reckhow and Z. Khan
Recognition
The presence of intrauterine adhesions may be
suspected in patients who present with cyclic or
chronic pelvic pain, amenorrhea, light menstrual
bleeding or other menstrual irregularities, and
infertility with or without recurrent pregnancy
loss, particularly in those with a history of prior
instrumentation of the endometrium [39]. A thin
endometrial stripe may be noted on standard twodimensional pelvic ultrasonography. Saline infusion sonohysterogram is the most sensitive
imaging modality for identifying IUA (Fig.5.4)
[40, 41]. Denitive diagnosis requires direct
visualization of intrauterine adhesions by hysteroscopy [42].
Management
Surgical management is indicated in symptomatic patients and may improve future fertility outcomes in those affected by infertility and/or
recurrent pregnancy loss. Hysteroscopic lysis of
adhesions, either in the ofce or outpatient surgical setting, is the gold standard treatment for
intrauterine adhesive disease [43]. When lysing
adhesions, the surgeon should use gentle blunt
dissection when possible (for example, allowing
distention of the uterus or the tip of the hysteroscope to break apart lmy adhesions) and favor
the use of cold instruments such as hysteroscopic
scissors to minimize the risk of injury to healthy
endometrium [44]. Electrosurgical instruments
should be used sparingly but may be essential for
hemostasis in some cases. Hysteroscopic morcellator devices may be useful for the resection of
excess tissue in patients with retained products of
conception or endometrial polyps. In general,
adhesiolysis should begin at the internal cervical
os with careful progression towards the fundus,
beginning with centrally located adhesions before
progressing laterally and nally to the uterine
cornua [21]. Filmy adhesions should be addressed
rst (Fig. 5.5a–b). Fluoroscopic or ultrasound
guidance may be utilized in particularly challenging cases to minimize the risk of uterine perforation or entry into myometrial tissue [45].
ab
5 Uterine Surgery forInfertility
Fig. 5.5 (a–b) Hysteroscopic view of intrauterine adhesive disease before (a) and after (b) hysteroscopic
adhesiolysis
49
Uterine Perforation
appropriate path is taken. Transabdominal or
transvaginal ultrasound guidance may also be
Background
utilized to prevent the formation of a false passage and uterine perforation. Electrosurgical
Uterine perforation occurs in 0.1–4% of gynecologic procedures that involve instrumentation of
the uterine cavity and may occur with the use of
instruments should only be activated when the
operator has a clear view and control of the active
instrument tip [48].
blunt, sharp, and heated instruments (Fig.5.6a–
b). The risk of perforation may be increased in
cases of difcult entry, including in the setting of
Recognition
acute version and/or exion of the uterus, cervical stenosis, nulliparity, and prior pelvic surgery
or cervical procedures [46–48]. The recently
gravid uterus may also be more susceptible to
uterine perforation due to myometrial relaxation.
Uterine perforation is often recognized by the
tactile sensation of a loss of resistance or entry of
an instrument beyond a reasonable depth. It may
also be recognized visually with ultrasound or
hysteroscopy. During hysteroscopy, rapid loss of
visualization or collapse of the uterine cavity
Prevention
suggests perforation [50]. If the procedure is performed with the assistance of a uid management
Many cases of uterine perforation can be prevented by careful instrumentation. In cases where
system, a sudden increase in uid decit can also
be seen in cases of uterine perforation.
cervical stenosis is anticipated, preoperative
misoprostol may decrease the risk of perforation
during dilation of the cervix [49]. Deep intracer-
Management
vical injection of vasopressin in these cases
decreases the force required for cervical dilation
[47]. Finally, if the external cervical os is dilated,
the hysteroscope can be utilized for hydrodilation
under direct visualization to ensure that the
In the event of uterine perforation, a period of
extended observation is appropriate to monitor
for signs of possible bleeding, increased pain,
and infection. When secondary to blunt instru-
50
Dilator vs bipolar
Anteverted uterus
Retroverted uterus
Fig. 5.6 (a–b) Uterine
perforation occurs when
an instrument passes
through the wall of the
uterus (a). Uterine
perforation is most
likely to occur through
the posterior wall in the
anteexed uterus, and
through the anterior well
in the retroexed uterus
(b)
J. Reckhow and Z. Khan
hysteroscopic instrument
ab
Arrow indicates direction of travel of device
mentation there is a low risk of bleeding or visceral injury, and observation is typically
sufcient. If there is concern for possible viscus
or other intrabdominal injury, diagnostic laparoscopy should be performed to assess the abdomi-
Vagina
Cervix
nal cavity [51, 52]. If perforation occurred
secondary to a sharp or heated instrument, diagnostic laparoscopy is recommended as the risk
for intraabdominal bleeding, and visceral injury
is higher with these instruments [46].
5 Uterine Surgery forInfertility
51
Uterine Rupture andAbnormal
Placentation
Background
Uterine rupture and abnormal placentation are
extremely rare but potentially catastrophic pregnancy complications that may occur as a result of
myometrial thinning after surgical intervention
as well as disruption of the junctional zone and
scar tissue formation between the endometrium
and myometrium following myomectomy or adenomyomectomy [53]. The risk of uterine rupture
may be increased after myomectomy, adenomyomectomy, hysteroscopic curettage, and hysteroscopic septoplasty and is estimated to occur in
0.1–1% of these cases, consistent with the risk
incurred after one or two low transverse Cesarean
births [54]. The risk appears to be highest among
patients who undergo laparoscopic as opposed to
open myomectomy, and this is suspected to be
due to less optimal closure of the myometrial
defect with the minimally invasive approach [55,
56]. The risk for placenta accreta spectrum (PAS)
is highest in patients with prior full-thickness
uterine surgery, such as extensive myomectomy
or adenomyomectomy but may be as high as 2%
among patients who have undergone hysteroscopic intrauterine adhesiolysis [57].
Additionally, it is important to remember that the
pathophysiology of adenomyosis, with the formation of stula-like canals within the myometrium, may predispose to PAS as well [58].
Prevention
Proper surgical technique facilitates effective
healing after invasive uterine surgery. Multilayer
closure of the myometrium and judicious use of
electrosurgery decrease the risk of uterine rupture after myomectomy and adenomyomectomy
[59–61]. The Use of barbed suture helps with
obtaining close reapproximation of the myoma
bed, reducing hematoma formation and promoting efcient wound healing [3]. Planned late preterm Cesarean birth is recommended in
pregnancies after extensive myomectomy, particularly if it is transmural or enters the endome-
trial cavity, and after adenomomectomy due to
the increased risk of uterine rupture in these
patients [62].
The prevention of catastrophic complications
of uterine rupture and abnormal placentation
relies on early recognition of these pathologies.
Patients with a history of prior uterine surgery
should undergo detailed obstetric ultrasonography to evaluate placentation in the second trimester. Further evaluation with MRI is recommended
if PAS is suspected [63]. Screening should also
be considered in patients with signicant antepartum bleeding or uterine pain, as these symptoms may reect abnormal placentation or
thinning of the uterine wall [64]. Catastrophic
complications of PAS, including life-threatening
hemorrhage, uterine rupture, and need for emergent delivery with postpartum hysterectomy, can
be prevented with judicious antepartum monitoring and planned medically indicated preterm
birth at a facility with hysterectomy capabilities
[65].
Recognition
The earliest sign of uterine rupture is usually fetal
heart rate changes; however, suspicion should be
raised in the event of loss of fetal station during
labor, sudden onset severe abdominal pain with
or without vaginal bleeding, and loss of intrauterine pressure [53]. As previously discussed, PAS
is ideally identied in the antenatal period on
imaging. If not previously recognized, it may be
diagnosed at the time of delivery as the placenta
will fail to separate and no plane will be appreciated between the placenta and the uterine wall.
These cases may present with uterine atony and
postpartum hemorrhage as well [53].
Management
Uterine rupture is an obstetric emergency and
requires immediate birth via Cesarean delivery.
Depending on patient stability and the extent of
the rupture repair of the uterus may be possible,
although hysterectomy is often required [66].
PAS is commonly managed by planned Cesarean
52
Distentio
J. Reckhow and Z. Khan
hysterectomy (please see Chap. 30, Cesarean
Hysterectomy, for additional details about this
procedure). In appropriate cases, the placenta
may be left in situ at the time of delivery with
plan for close interim monitoring and interval
removal after placental involution [67, 68].
Volume Overload
withHysteroscopic Procedures
Background
Modern-day hysteroscopy utilizes distension
media for expansion of the uterine cavity to allow
for visualization and targeted treatment of intrauterine pathology. Though generally considered a
low-risk procedure, hysteroscopy can precipitate
major hemodynamic complications, particularly
in the setting of suboptimal uid management.
Prevention
An automated uid management system should
be utilized to allow for objective tracking of
absorption of distention media (Fig. 5.7).
Procedures should be completed expeditiously
by skilled surgeons and should be performed at
the lowest possible uid pressure that allows for
adequate visualization (usually 60–80 mmHg)
[48]. Intravascular hydration should be kept to a
minimum during the procedure to minimize
cumulative uid intake. When a complex procedure is anticipated, intracervical injection of
vasopressin may be considered as vasoconstriction may further decrease intravascular uid
absorption during the case [69].
n
media
Outflow
collection
cannister
Fig. 5.7 Demonstration of a typical simple hysteroscopy uid management system
Inflow
Outflow
Hysteroscope
5 Uterine Surgery forInfertility
53
Recognition
Pulmonary and cerebral edema may develop rapidly with overabsorption of distention media and
are typically rst detected by new onset ventila-
Management
Table 5.2 highlights management recommendations for complications that may arise with commonly used distention media.
tion difculty, crackles or rales on pulmonary
auscultation, brady- or tachyarrhythmias, altered
mental status, and hypotension. These conditions
frequently develop during or shortly after the
procedure is completed or terminated [48, 70].
Table 5.2 Media Selection and Considerations for Hysteroscopy
Type of Media
Electrolyte-rich Electrolyte-poor Gaseous
Examples Normal saline (isotonic)
Lactated Ringer’s (isotonic)
Uses Diagnostic or operative
hysteroscopy in which
mechanical, laser, or bipolar
energy sources are used
Advantages Low cost
Readily available in most clinical
settings
Good electrical conductor so can
be used with bipolar energy
sources
Disadvantages Cannot be used with monopolar
energy sources
Maximum
uid decit
2500cc. Consider terminating
procedure at 2000cc
1.5% glycine (hypotonic)
2.5–5% sorbitol (hypotonic)
5% Mannitol (hypotonic)
Dextran 70 (hypertonic)
Operative hysteroscopy with
monopolar electrosurgery only
Does not conduct electricity so
can safely be used with
monopolar energy sources
Due to high viscosity, dextran
does not readily spill into the
peritoneal cavity or mix with
blood
Allows for better visualization
in bleeding scenarios as blood
does not mix with the
distension medium
Cannot be used with bipolar
energy sources
Allergy and contraindications
are more common
1000cc for hypotonic
solutions. Consider
terminating procedure at
750cc.
500cc for high-viscosity
solutions. Consider
terminating procedure at
300cc.
CO
2
Diagnostic hysteroscopy
only, primarily in the ofce
setting
Low cost
Conducts light well so
provides optimal
visualization
Readily absorbed into
bloodstream and removed
via pulmonary ventilation
so risk of accumulation is
low
Uneven distention of the
uterine cavity, inability to
clear secretions, and blood
can result in poor
visualization
N/A
(continued)
54
Table 5.2 (continued)
Type of Media
Electrolyte-rich Electrolyte-poor Gaseous
Major risks Excessive uid absorption can
cause isotonic volume overload,
pulmonary edema, and congestive
heart failure
Air embolism is uncommon but
may occur when ambient pressure
is greater than diastolic venous
pressure.
Prevention Volume overload: Prevent with
continuous inow–outow
monitoring
Air embolism: Minimize duration
and extent of Trendelenburg
positioning; remove speculum
once hysteroscope is inserted into
the uterus and limit
reinstrumentation to minimize
exposure of the dilated cervix to
the air; clear air from inow tracts
of hysteroscope
Recognition Volume overload: Decreasing
oxygen saturation, crackles on
pulmonary auscultation
Air embolism: Chest pain and
dyspnea, decreased end tidal CO2,
hypotension, tachycardia,
mill-wheel murmur on cardiac
auscultation
Excessive absorption can
cause euvolemic hyponatremia
and decreased serum
osmolality, increasing the risk
for seizures, cerebral edema,
coma, and death.
Glycine is metabolized into
ammonia and glycol, which
can cross the blood–brain
barrier resulting in
hyperammonemia.
Sorbitol and mannitol have
diuretic effects and may cause
severe dehydration and
subsequent hypotension and
circulatory collapse
Prevent volume overload and
rapid intravasation with
continuous inow–outow
monitoring. Consider
intracervical injection of
vasopressin to minimize
intravascular uid absorption.
Hyponatremia: Muscle
twitching, hypotension,
tachycardia, seizures
Hyperammonemia: Agitation,
somnolence, dizziness, visual
disturbances, vomiting, coma
J. Reckhow and Z. Khan
Gas embolism
Maintain low distention
pressure (<100mmHg)
and minimize operative
time. Never use a
laparoscopic insufator in
place of a hysteroscopic
insufator as the ow rates
differ between these
devices.
Early signs: Cardiac
arrhythmia, rising end-tidal
CO2, decreasing oxygen
saturation
Early symptoms: Chest
pain, shortness of breath
Late signs: Sudden drop in
oxygen saturation,
hypotension, pulmonary
hypertension, hypercarbia,
tachypnea
(continued)
5 Uterine Surgery forInfertility
Table 5.2 (continued)
Type of Media
Electrolyte-rich Electrolyte-poor Gaseous
Management Fluid restriction and diuretics Hyponatremia: Fluid
restriction and care by
intensive care specialist for
hyponatremia. Under the
intensivists’ care, slow
correction with isotonic or
hypertonic saline could be
considered.
Hyperammonemia: Consider
administration of lactulose
and/or rifaximin, consult
internal medicine or critical
care for assistance in
management
55
Immediately terminate the
procedure. With the
assistance of anesthesia
colleagues, place patient
on mechanical ventilation
with 100% FiO2, place
patient in left lateral
decubitus position and in
steep Trendelenburg to
minimize gas embolism
travel to the pulmonary
circulation.
Consider: IV uid
resuscitation with normal
saline, placement of a
central line to help remove
air from the right atrium,
pericardial thump to help
break up larger gas bubbles
Diminished Ovarian Reserve
andLoss ofOvary
Background
Surgery for infertility often includes intervention
on the ovary so it is important to consider ovarian
surgery when discussing complications of surgery
for infertility. Common adnexal pathologies seen
in reproductive-aged individuals include physiologic ovarian cysts, endometriomas, mature teratomas (dermoid tumors), and other benign ovarian
neoplasms such as cystadenomas. Minimally invasive ovarian cystectomy is the gold standard for
the management of these pathologies. In many
cases, such as with endometriomas and dermoid
tumors, disease may be bilateral or recurrent. This
makes conservative surgery even more desirable,
as future oophorectomy may be required [71].
While an initial decline in serum anti-mullerian
hormone (AMH) is noted after surgery, levels
return to normal within 3–6months in most cases
and within 12months for endometriomas; ovarian
cystectomy does not appear to have a meaningful
long- term impact on ovarian reserve or live birth
rates [72–77]. In patients with endometriosis who
desire future fertility, removal of ovarian endometriomas >4 cm in size improves pregnancy rates
[78]. This benet may not be seen with excision of
smaller endometriomas, and treatment of disease
with coagulation or laser evaporation without
pseudocapsule excision increases the risk of cyst
recurrence and associated symptoms hence is not
recommended [79].
Prevention
Benign lesions of the ovary should be removed
via cystectomy performed by an appropriately
skilled surgeon. Techniques to facilitate dissection of the cyst wall include the use of hydrodissection and injection of dilute vasopressin
(0.1–1 unit/mL) once the plane of the cyst is
identied [80]. If there is concern for oophorectomy, surgery should be performed by a skilled
reproductive surgeon to maximize the likelihood
of successful ovarian preservation [81].
56
J. Reckhow and Z. Khan
Recognition
It is important to recognize that bleeding is
expected during cystectomy and that ovarian cystectomy is a technically more complex procedure
than oophorectomy in most cases [82].
Management
Preventing loss of ovarian function and loss of
ovary at the time of ovarian surgery requires
patience and judicious hemostasis. Hemostatic
agents should be preferentially used for lowvolume oozing of the cystectomy bed, and suture
or electrosurgical techniques may be required to
control higher volume bleeds [83]. The choice of
hemostatic agent should be per provider preference as there is no difference in ovarian reserve
outcomes with different agents [18, 84, 85]. Use
of monopolar energy should be minimized as diffuse dispersion of energy throughout the ovary
may result in injury to healthy tissue; bipolar or
ultrasonic energy sources should be favored if
electrosurgical hemostasis is required [73, 86].
Ovarian suturing for the purpose of hemostasis
results in improved immediate post-operative
ovarian function preservation, although longterm ovarian reserve outcomes are the same [87,
88]. If oophorectomy is required, the patient
should be offered consultation with a reproductive endocrinologist to discuss options for fertility preservation, including ovarian tissue
cryopreservation [89–94].
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