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Hysteroscopic Myomectomy — 157
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28F, and the loop electrode comes with different angles. The telescopes also come with angles from 0
◦
to 30◦. Most surgeons are
limited to whatever their operating room has available to them;
however, if there is a choice, the surgeon should try different
sizes to determine the one with which he or she is most comfortable. With the current use of saline-infused ultrasound and
MRI, in most cases, the surgeon can be fairly certain that he or
she is dealing with a submucosal myoma. In these cases, it is
best to go directly into the cavity with the resectoscope and not
use the diagnostic scope first. The main reason is that there is
only so much fluid that the patient can absorb before the case
must be stopped. It is useless to waste this time on an initial survey with the diagnostic hysteroscope. The extremely rare risk of
cervical damage is far outweighed by the increased risk of fluid
overload.
The next important step is cervical dilatation. It is important
to not overdilate the cervix as this may lead to the loss of distention fluid aroundthe resectoscopeand difficulty indistending the
cavity to appropriately see the myoma. This may be a problem
in the case of a prolapsing myoma, in which the cervix is already
significantly dilated before starting the procedure. In a case in
which the cervix has been overdilated either by surgical error or
by a prolapsing myoma, the surgeon can try to occlude the cervix
by placing towel clamps either unilaterally or bilaterally on the
cervix. Anotheroption that is typically more successful in achieving the appropriateocclusionbuttakesmoretime involvesplacing
a cerclage-like stitch around the cervix that can be tied around
the resectoscope. The stitch can thenbe removed atthe end of the
procedure. It is also important not to underdilate the cervix as
larger myomas often require forward-and-backmovement of the
entire resectoscope. This movement may be limited if the cervix
is not sufficiently dilated, leading to possible complications.
The typical procedure is performed with a 12
◦
loop. The resectoscope is designed so that the electrode
a90
◦
telescope and
has a spring that brings it back to the sheath, which is insulated
at the end to protect the patient from inadvertent bleeding. The
electrode should be maximally extended to give the best visualization of the pathology during resection. The movement of the
electrode during resection should always be toward the operator. Movement away from the operator is more likely to result in
uterine perforation and potential serious injury to the patient.
There likely will be times when the loop is not visible as it should
be on the far side of the myoma to resect it toward the operator;
however, energy should be used only as the electrode is moved
toward the operator. For larger myomas, the entire resectoscope
must occasionally be moved with the electrode to shave off the
entire length.
While shaving the myoma, difficulties often occur with the
pieces. Occasionally, they get trapped between the electrode and
the lens. This can usually be corrected by separating the electrode
from thelens and making sure the flowof thedistention medium
is working. A piece of the myoma may also become attached to
the electrode. Surgeons often struggle in vain to remove these
pieces. If the surgeon simply continues the procedure, the piece
will typically come off with the next cut. Occasionally, the surgeon may find it difficult to cut through the myoma with the
electrode. This is typically because the power is set at too low a
wattage or the surgeon is using a coagulation current instead of
a cutting current. A cutting current wattage of 80 to 100 W is
typically adequate for smoothly slicing the myoma. The current
works better by arcing it toward the tissue, so it is best to start
the current just before the electrode actually makes contact with
the tissue and to continue the movement smoothly. Moving too
slowly may result in a coagulation of the tissue and a sticking of
the electrode. Moving too quickly may lodge the electrode into
tissue thathas not yetbeen cut. Usingthe coagulation currentat a
setting between 30 and 40 W is appropriate for stoppingbleeding
from any significant vessels from the myoma. It is not useful for
shaving the myoma as the peak voltage that is required makes
this more dangerous to peripheral tissue both in and outside the
uterus. Also, the intermittent current makes the cells less likely to
desiccate and therefore cut the tissue, and more likely to char the
tissue.
Bubbles may occur during cutting, as a result either of gas
forming during the cutting itself or of air in the inflow tubing.
These can be visually distracting to the operator. It is important
to maintaina good seal throughout the circuit of distention fluid.
When bubbles form in the cavity, placing the end of the resectoscope directly into the bubble and making sure that the outflow
is turned on will usually eliminate the problem.
With regard to removing the myoma, there is debate as to
how aggressive the surgeon should be. Many surgeons believe
that for maximal safety, an operator should not resect below the
endometrial surface. One would automatically believe that this
may leave a significantpart of themyomabehind. However, when
the myoma is shaved from the cavity, surgeons will find that
the normal contractile nature of the uterus tends to force the
intramural portion of the myoma into the cavity. It is frequently
possible to remove the entire myoma in this fashion without
actually having to dissect below the endometrial surface. For this
technique to be successful, it is necessary to have at least 40% to
50% of the myoma protruding into the cavity when starting the
procedure.
Some surgeons insist that it is prudent to remove the entire
myoma regardless of the depth in which it is situated in the
myometrium. Although itis true thatthe procedure is more likely
to achieve long-term success when the entire myoma is removed,
the risks of perforation and subsequent injury to bowel or vascular structuresincrease significantly as one dissects deeper intothe
myometrium. Ultrasound guidance occasionally has been used
to determine depth and distance from the serosa, but it does not
eliminate the potential risks. Indman[20]proposedinjecting carboprost, a methyl analogue of prostaglandin F
, into the cervix.
2α
He reported ona series of13 patients witha significant amountof
the submucosal myoma intramural. He found that thecarboprost
caused uterine contraction, allowing 11 of the 13 myomas to be
completely excised. No randomized study has been performed,
and as this frequently happens without any injection,it isunclear
whether carboprost truly makes any difference. As a general rule,
a surgeon should proceed with extreme caution when dissecting
below the endometrium.
Although it is a relatively safe procedure compared with
abdominal myomectomy, hysteroscopicmyomectomyhas potential risks as well. The risks of fluid overload and hyponatremia
are discussed earlier in this section. The risk of uterine perforation is higher in resectoscope cases. The cervix must be dilated to
a greater amount to accommodate the large instrument, which
may lead to perforation during dilatation. This is usually recognized once the scope is place, either because it goes directly
into the abdominal cavity or because there is an immediate fluid
158 — Charles J. Ascher-Walsh and Michael Brodman
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Table 8.3.1: Hysteroscopic Myomectomy for Abnormal Uterine Bleeding
Study Cases, no. Follow-up, %
Polena et al. [21] 235 84 40 94.4
Wamsteker et al. [22] 51 93.3 20 93.3
Emanuel et al. [23] 285 94 46 85.5
Cravello et al. [24] 196 86.2 73 82.2
Marziani et al. [25] 84 97 36 80.9
Kuzel et al. [26] 45 100 48 100
Hart et al. [27] 194 100 27 79
Munoz et al. [28] 120 100 36 88.5
Brooks et al. [29] 90 100 6 91
Derman et al. [30] 177 100 108 83.9
imbalance. If the perforation occurs before the use of the electrode, the procedure must be stopped; however, the patient usually may simply be monitored in the recovery room for signs
of intra-abdominal bleeding. Stable serial hemoglobin levels are
reassuring, and the patient can be sent home and the procedure
reattempted another day.
If the perforation occurs with the resectoscope while the electrode is charged, the potential for serious injury exists.Thepatient
must have a thorough evaluationofthe abdomen and pelvis,typically via laparoscopy, todetermine thepresence and extent of any
injury. Unfortunately, thermal injuries to the intestine are not
always readily apparent. If the bowel has been burned but not
incised, the defect may only become apparent after a few days.
Patients discharged home after this type of complication should
be advised to monitor theirtemperature and report any gastrointestinal symptoms, specifically nausea and vomiting.
Another possible complication afterthis procedure,especially
in patients with a desire for future fertility, is intrauterine adhesions. These are more likely if two opposing fibroids have been
resected so that the surfaces are juxtaposed after the procedure is
completed. Although this is rare, should it occur, the surgeon has
the option of giving the patient supplemental estrogen immediately postoperatively, with the goal of rapidly developing the
endometrium to prevent adhesions. Another method attempted
in the past was the placement of an intrauterine Foley catheter to
keep the opposing surfaces away from one another until estrogen
formed spontaneously.
The immediate postoperative care of patients having undergone hysteroscopic myomectomy is generally not complicated. If
an imbalance of fluid was noted during the procedure, the recovery room nurse should monitor the patient for signs and symptoms offluid overload and hyponatremia, including bradycardia,
hypertension, nausea,vomiting,seizures, pulmonary edema, and
cardiac abnormalities. The management of these problems has
been previously discussed. There is typically not much pain after
this procedure. At our institution, we find that ketorolac 30 mg
given IV soluset at the completion of the procedure is usually
adequate anesthesia; our patients are not sent home with narcotics but are told to use an anti-inflammatory medication such
Average Follow-up
Time, months
Success (No Further
Surgery), %
as ibuprofen. The need for more significant pain control can be
an indication of a more serious injury during the surgery and
should be evaluated appropriately.
Patients should be told to expect per vaginal bleeding for
approximately 1 week after the surgery. The duration of bleeding
may vary from a few days to 2 weeks, but the flow usually is
very light. Patients should also be warned that their cycle may be
abnormal for the next month or two and a heavy menses following
the procedure is not indicative of what their usual menses will be
like once they return to a regular cycle.
LONG-TERM RESULTS: MENORRHAGIA
AND FERTILITY
Most studies evaluating the results of hysteroscopic myomectomies specifically focus on subsequent fertility and menorrhagia. The only true cure for uterine myomas is a total hysterectomy. Even women undergoing a supracervical hysterectomy for
myomas should be advised that there is a very small risk of developing a cervical myoma in the future. It is therefore inherent
in the hysteroscopic myomectomy procedure that a success rate
of 100% should not be expected. Some surgeons argue that the
immediate, postoperative results should be close to 100% of the
time. However, many women have anatomically normal uteruses
with menorrhagia, dysfunctional uterine bleeding. It is impossible to know whether a woman with a submucosal myoma is
bleeding irregularly solely because of the myoma or because of
some other undetectable problem in her uterus. Only by removing the myoma would this be found; however, its presence would
be considered asurgical failure, even thoughthe goal ofremoving
the myoma may have been completely successful. We know from
data on abdominalmyomectomiesthat up to 30%of women who
undergo the procedure will require an intervention for myomas
in the future. There is no reason to believe that this should not
be the case for patients with submucosal myomas as well.
Studies now exist looking at the 1- to 9-year follow-up of
hysteroscopic myomectomies. Table 8.3.1 exhibits the results for
patients treated specifically forabnormal bleeding. Hysteroscopic
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Table 8.3.2: Fertility Rates after Hysteroscopic Myomectomy
Study Patients, no. Follow-up Period, months % Followed % with Pregnancies
Ubaldi et al. [31] 134 NA NA 58.9
Goldenberg et al. [32] 15 12 100 47
Shokeir [33] 29 24 100 72.4
Bernard et al. [34] 31 24 100 35.5
Giatras et al. [35] 41 24 100 60.9
myomectomy has at least an 80% success rate for up to 9 years
after surgery. Although it may seem that a failure rate of 20% is
significantly high for any procedure, it is important to remember that the alternative would have been for the patients to have
undergone ahysterectomy, withits associated increasein complications, pain, and lost productive time. In these studies, approximately half the patients who failed the procedure required a
hysterectomy subsequently and the others had other forms of
intervention, usually another hysteroscopy. At least 90% of these
patients were able to avoid a hysterectomy by undergoing a minimally invasive outpatient procedure that has considerably fewer
risks.
Infertility isanother common reason for undergoinghysteroscopicmyomectomy.Again, infertility ismultifactorial,andmany
patients who are infertile will not be found to have any apparent
problems. It is very possible that a woman may have infertility from an unknown source and have a submucosal myoma as
well, so fertility rates after resection of myomas should be evaluated with this information in mind. Table 8.3.2 reports the findings from a number of studies designed to evaluate fertility after
hysteroscopic myomectomy. Pregnancy rates vary from 35% to
70%, representing a dramatic increase in fertility after hysteroscopic myomectomy in patients having infertility and a submucous myoma. Given that these women typically would have had
limited options–amyomectomy,withitsassociated morbidity,
or a hysterectomy, which clearly eliminates any chance of fertility in the future – hysteroscopic myomectomy represents a great
advancement.
NEW TECHNIQUES
Surgeons are always trying to improve on current techniques in
an attempt to decrease operative risks and improve outcomes.
The development of the hysteroscopic myomectomy is an example of this, and within the context of the hysteroscopic myomectomy, advances continue. Because of thefluidbalance risks, better
fluid management systems have emerged over the last few years
that greatly enhance the surgeon’s ability to closely monitor the
fluid balance to significantly decrease the risk of the patient ever
developing hyponatremia or general fluid overload. The most
advanced system would monitor input and output, maintain a
hysteroscopic intrauterine pressure sufficient to distend the cavity but not excessive, present all these data on the video screen
used for theprocedure,and have alarms to alertthe surgeon when
any parameters reached levels of increased risk. Surgeons would
have to consciously choose to ignore the warnings to cause harm.
As with any device, there is always the risk of instrument error,
so the surgeon should not have a complete sense of security with
this instrumentation. Having the equipment decreases the risks
but does not excuse the surgeon from monitoring all aspects of
the surgery closely so as to catch equipment errors if they arise.
Although there is no correction for poor surgical technique or
judgment on the part of the surgeon, new devices limit the risk
as much as possible.
Because a monopolar electric current is somewhat uncontrolled once it leaves the electrode, many surgeonsbelieve a bipolar device is safer. With the standard monopolar electrode, the
current has its greatest effect within millimeters from the electrode. It is then dispersed in all directions and is reaccumulated
at the grounding pad and returned to the generator. The dispersed current is usually too weak to cause harm. The current
will flow in a path of least resistance. In the setting of a hysteroscopic myomectomy, the myoma and the tissue surrounding it
generally have a uniform resistance, so the current flows in all
directions. If there is aberrant anatomy, it is possible that a channel of less resistance might exist, concentrating the current and
potentially harming the patient. This is the reason the grounding
pads are wide: if they were attached at a single point, the entire
current would accumulate at that point and cause injury.
Bipolar instruments have opposing electrodes that are positive and negative, so thecurrentflows only between theelectrodes
and isnotdispersedthroughoutthepatient.Thismore-controlled
current should be safer as it is not dispersed through the patient.
The VersaPoint system by Gynecare is an example of a system
with this design. Clark et al. [36] performed a feasibility study on
this technique, which they reported in 2002. Using the bipolar
device, they operated on 37 women with a submucous myoma.
They found that 92% of the patients were satisfied with the procedure, although only 78% reported improvement in bleeding.
There were no operative complications, and the authors considered this technique to be an improvement over the standard
monopolar technique.
In addition to the increased safety of the better-controlled
current, bipolar techniques offer other advantages. Using a bipolar electrode allows the surgeon to use normal saline as the distending fluid. Although this does not eliminate the risks of fluid
overload, it greatly decreases the risk of hyponatremia. This does
not eliminate the need for close fluid monitoring, as at least one
death has occurred as a result of fluid overload using this system. However, it increases the amount of fluid that may be safely
absorbed to 2000 to 2500 mL, which may give the surgeon valuable additional time to perform the procedure completely.
The bipolar technique also has improved with regard to
the tissue affected by the current. In most cases, as the electrode is moved through the myoma, it completely vaporizes the
160 — Charles J. Ascher-Walsh and Michael Brodman
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tissue. This eliminates or greatly decreases the amount of floating pieces of myoma that obscure the operative field, which may
both lengthen the procedure and increase operative errors due
to the obstructed view. One negative would be that the tissue is
not evaluated by a pathologist to assure that the treated lesion is
indeed a simple myoma and not a more serious condition, such
as a sarcoma. This is very rare, however, and may not outweigh
the benefits offered by this technique.
Another new technique eliminates the risk of electrosurgery.
The Smith & Nephew operative hysteroscopy system involves a
rotatingmorcellatingblade.Theopening isonthe sideofthedistal
end of the hysteroscope. This opening is placed on the myoma,
and the rotating blade shaves the myoma. The cutting is all sharp
as no electric current is used. The shaved pieces are immediately
suctioned out of the uterus through the scope and collected for
pathologic review. This technique uses the normal contraction
of the uterus that occurs during a hysteroscopic myomectomy
to both force the myoma out of the myometrium and contract
the vessels surrounding the myoma to decrease bleeding. This
technique limits the surgeon’s ability to dissect deeper into the
uterine wall to remove the entire myoma if it is not expelled
by uterine contraction, a limitation that is probably safer for
the patient. The procedure, like the bipolar technique, may be
performed with normal saline, with the same decreased risk of
hyponatremia. Surgeons shouldhavesome type of electrosurgery
device available to manage bleeding should it occur.
The opportunity to improve patient care drives those in the
medical field toconstantly search for newdevices and techniques.
With the adoption of the resectoscope, gynecologists have been
able to save countless women from experiencing excessive pain,
lost productive time, and unnecessary major surgery. Although
risks exist in everything we do as surgeons, the resectoscope
greatly reduces those involved in surgeries for uterine myomas.
Advances continue to reducethese risks and make the options for
treatment of uterine myoma safer for women suffering from the
effects of this condition.
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1. Neuwirth RS, AminHK. Excision ofsubmucous fibroids with hysteroscopic control. Am J Obstet Gynecol. 1976;126:95–99.
2. Nesbit RM. A history of transurethral prostatic resection. In: Silber SJ, ed. Transurethral Resection. New York: Appleton-Century-
Crofts; 1977:1–17.
3. Stern M. Resection of obstruction at the vesical orifice. JAMA.
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7. Iglesias JJ, SporerA, Gellman AC, SeebodeJJ.New Iglesias resectoscope with continuous irrigation, simultaneous suction, and low
intravesicle pressure. JUrol. 1975;114:929–933.
8. Baggish MS, Brill AI, Rosensweig B, Barbot JE, Indman P. Fatal
acute glycine and sorbitol toxicity during operative hysteroscopy.
J Gynecol Surg. 1993;9:137–143.
9. Loffer FD. Complications from uterine distention during hysteroscopy. In: Corfman KS, Diamond MP, DeCherney A, eds.
Complications in Laparoscopy and Hysteroscopy. Boston: Blackwell
Scientific Publications; 1993:117–186.
10. Cepni I, Ocal P, Erkan S, et al. Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of the uterine cavity pathologies. AustNZJObstetGynaecol.
2005;45(1):30–35.
11. de Vries LD, Dijkhuizen FP, Mol BW, Brolmann HA, Moret E,
Heintz AP. Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women
with abnormal uterine bleeding. J Clin Ultrasound. 2000;28(5):
217–223.
12. Salim R, Lee C, Davies A, Jolaoso B, Ofuasia E, Jurkovic D. A
comparison study of three-dimensional saline infusion sonohysterography and diagnostic hysteroscopy for the classification of
submucous fibroids. Hum Reprod . 2005;20:252–257.
13. Nilsson L,Rybo G.Treatmentofmenorrhagia.AmJ ObstetGynecol.
1971;110:713–720.
14. Brooks PG, Serden SP. Preparation of the endometrium for ablation with a single dose of leuprolide acetate depot. JReprodMed.
1991;36:477–478.
15. Friedman AJ, Hoffman DI, Comite F, Browneller RW, Miller JD.
Treatment of leiomyomata uteri with leuprolide acetate depot
– a double blind, placebo controlled multicenter study. Obstet
Gynecol. 1991;77:720–725.
16. Coddington CC, Brzyski R, Hansen KA, Corley DR, McIntyreSeltman K,JonesHW.Shortterm treatmentwithleuprolide acetate
is a successful adjunct to surgical therapy of leiomyomas of the
uterus. Surg Gynecol Obstet. 1992;175:57–63.
17. Perino A, ChianchianoN, PetronioM, Cittadini E. Role of leuprolide acetatedepotinhysteroscopic surgery: a controlledstudy.Fertil
Steril. 1993;59:507–510.
18. Gimpelson RJ, Kaigh J. Mechanical preparation of the
endometrium prior to endometrial ablation. JReprodMed.
1992;37:691–694.
19. Lefler HT, Sullivan GH, Hulka JF. Modified endometrial ablation
electrocoagulation with vasopressin and suction curettage preparation. Obstet Gynecol. 1991;77:949–953.
20. Indman P. Useof carboprost tofacilitate hysteroscopicresection of
submucous myomas.J AmAssoc Gynecol Laparosc. 2004, 11(1):68–
72.
21. Polena V, Mergui JL, Perrot N, Poncelet C, Barranger E,
Uzan S. Long-term results of hysteroscopic myomectomy in
235 patents. Eur J Obstet Gynecol Reprod Biol. 2007/Feb;130(2):
272–7.
22. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension.
Obstet Gynecol. 1993;82(5):736–740.
23. Emanuel MH, Wamsteker K, Hart AA, Metz R, Lammes FB. Long
term results of hysteroscopic myomectomy for abnormal uterine
bleeding. Obstet Gynecol. 1999;93(5 pt 1):743–748.
24. Cravello L,Farnarier J,RogerV,D’Ercole C, Blanc B.Hysteroscopic
myomectomy. Functional results with an average follow-up of 6
years. J Gynecol Obstet Biol Reprod. 1998;27(6):593–597.
25. Marziani R, Mossa B, Ebano V, Perniola G, Mellusa J, Napolitano C. Transcervical hysteroscopic myomectomy: long term
effects on abnormal uterine bleeding. Clin Exp Obstet Gynecol.
2005;32(1):23–26.
26. Kuzel D, Toth D, Fucikova Z, Cibula D, Hruskova H, Zivny. Hysteroscopic resection of submucosal myomas in abnormal uterine bleeding: results of a 4-year prospective study. Ceska Gynecol.
1999;64(6):363–367.
27. Hart R,MolnarBG,MagosA.Longtermfollowup ofhysteroscopic
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28. Munoz JL, Jimenez JS, Hernandez C, et al. Hysteroscopic
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29. Brooks PG, Loffer FD, Serden SP. Resectoscopic removal of symptomatic intrauterine lesions. JReprodMed. 1989;34(7):435–437.
30. Derman SG, Rehnstrom J, Neuwirth RS. The long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas.
Obstet Gynecol. 1991;77(4):591–594.
31. Ubaldi F, Tournaye H, Camus M, Van der Pas H, Gepts E, Devroey
P. Fertility after hysteroscopic myomectomy. Hum Reprod Update.
1995;1(1):81–90.
32. Goldenberg M, Sivan E, Sharabi Z, Bider D, Rabinovici J, Seidman
DS. Outcome of hysteroscopic resection of submucous myomas
for infertility. Fertil Steril. 1995;64(4):714–716.
33. Shokeir TA. Hysteroscopic management of submucous fibroids to
improve fertility. Arch Gynecol Obstet. 2005;273(1):50–54.
34. Bernard G, Darai E, Poncelet C, Benifla JL, Madelenat P.
Fertility after hysteroscopic myomectomy: effect of intramural
myomas associated. Eur J Obstet Gynecol Reprod Biol. 2000;88(1):
85–90.
35. Giatras K, Berkeley AS, Noyes N, Licciardi F, Lolis D, Grifo JA.
Fertility after hysteroscopic resection of submucous myomas. J
Am Assoc Gynecol Laparosc. 1999;6(2):155–158.
36. Clark TJ,MahajanD,SunderP,Gupta JK. Hysteroscopictreatment
of symptomatic submucous fibroids using a bipolar intrauterine system: a feasibility study. Eur J Obstet Gynecol Reprod Biol.
2002;100(2):237–242.
Section 8.4. Hysteroscopic Tubal Cannulation
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Tommaso Falcone and Jeffrey M. Goldberg
The concept of cannulating the intramural portion of the tube
to relieve an obstruction in infertile patients has been around
since the 19th century. Tubal cannulation is also performed for
diagnostic assessment,transfer of gametes or embryos, andsterilization. The radiologic and hysteroscopic approaches to relieving
obstruction were investigated in the mid-1980s and remain an
integral part of infertility treatment.
DIAGNOSIS OF PROXIMAL TUBAL BLOCK
Approximately 25% to 30% of infertility in women is the result
of tubal disease, with proximal tubal occlusion (PTO) accounting for the infertility in 10% to 25% of those patients.[1] Hysterosalpingogram (HSG) is the first-line technique for excluding
anatomic defects in the uterine cavity and documenting tubal
patency in infertility patients. It is part of the basic infertility
work-up and is normally required in every patient.[2] PTO is
found on 10% to 20% of hysterosalpingograms [1] and may
be caused by obstruction due to tubal spasm or plugging by
mucus and amorphous material or by occlusion from fibrosis
or endometriosis. Infectious causes include salpingitis isthmica
nodosa (SIN), pelvic inflammatory disease (PID), and tuberculosis. These infections maydamage otherareas of the tube,which
will affect the prognosis of the treatment.
HSG is considered the standard test for assessment of the
uterine tubes in patients with infertility. If HSG suggests patent
tubes, tubal blockage is highly unlikely.[3] One study noted that
60% of patients with PTO on HSG were patent on repeat HSG
1 month later.[4] Similarly, tubal blockage on HSG is not confirmed by laparoscopy in up to 62% of patients.[3] It should be
noted that laparoscopy is not the perfect gold standard as 2%
of patients with bilateral tubal occlusion subsequently conceived
spontaneously.[5] Also, Sulak et al. [6] reported that 11 of 18
patients with bilateral PTO on both HSG and laparoscopy were
patent histologically.
Diagnostic laparoscopy and hysteroscopy to assess the uterus
and tubes are probably more cost-effective than HSG in patients
with pelvic pain, adnexal masses, or other indications for surgery
as well as a history of PID or prior pelvic surgery. These patients
are much more likely to have pelvic pathology requiring surgical
treatment, regardless of the results of HSG.
MANAGEMENT OF PROXIMAL TUBAL
BLOCKAGE
Historically, PTO was managed by coring out the uterine cornua and implanting the proximal fallopian tube within the
endometrial cavity. The procedure was abandoned because of
low pregnancy rates and increasedriskfor cornual rupture during
pregnancy.Itwasreplaced with microsurgical resectionandanastomosis in the late 1970s. Transcervical tubal cannulation by fluoroscopic guidance was first reported in 1985 [7]; hysteroscopic
tubal cannulation was reported 2 years later.[8]
As noted above, 60% of patients with PTO on HSG were
shown to be patent on repeat HSG 1 month later.[4] Therefore,
selective salpingography may be attempted if a repeat HSG at
least 1 month later confirms persistent PTO. The repeat HSG is
performed underintravenous conscious sedationusing a balloon
catheter with a5F catheter advanced through it andwedged in the
cornua under fluoroscopic guidance. Contrast is then injected,
establishing patency in a third of the tubes.[9]
Tubal cannulation may be attempted in the two thirds of
tubes that remained occluded during selective salpingography. A
flexible guidewire is then passed through the tubal ostium and, if
successful, a 3F catheter is advanced over the wire and contrast is
injected (Figure 8.4.1). In one study, the procedure successfully
established patency in more than 85% of cases.[1] After relieving
the obstruction, distal tubal disease may be found (Figure 8.4.2).
Excision of the proximal tubes in cases of failed tubal cannulation revealed SIN, chronic salpingitis, or fibrosis in 93% of
patients in one study.[10] About a third of the opened tubes
reocclude.[1,9] Tubal perforation has been reported in 3% to
11% of cases but has always been innocuous.[11]
Laparoscopy with transcervical chromotubation with dilute
indigo carmine should beperformedtoconfirmPTOininfertility
patients whohave not had a diagnostic laparoscopy or in patients
with known pelvic disease. Hysteroscopic cannulation may be
attempted at that time if persistent PTO is noted. Success rates in
terms of patency,reocclusion,andperforation are nearly identical
tothoseforradiologic cannulation,butpregnancyratesarehigher
with the hysteroscopic approach.
Ongoing pregnancy rates following hysteroscopic tubal cannulation were similar to those for microsurgical resection and
anastomosis of PTO: almost 50%. In this study report that analyzed several studies,theradiologic group wasdividedinto “highsuccess” and “low-success.” [1] However, the ongoing pregnancy
rate after fluoroscopic canalization was significantly lower in the
high-success group: 29%. The overall pregnancy rate in the lowsuccess group wasonly 12.2%, with inadequate data to determine
pregnancy outcomes. Unfortunately, there was no way to distinguish between thesegroups from the studies(Table 8.4.1).[1] The
higher pregnancy rate with the hysteroscopic approach is likely
the resultof the fact that other pelvic pathology can bediagnosed
and treatedlaparoscopically, whereas concurrent pelvic disease is
unrecognized with fluoroscopic tubal cannulation.
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Table 8.4.1: Pregnancy Rates Following Treatment of
Proximal Tubal Blockage
Figure 8.4.1. Fluoroscopic tubal cannulation. The arrow indicates the
end of the outer catheter in the cornua, and the arrowhead is the tip of
the inner catheter within the proximal tube.
TECHNIQUE
The contraindications tohysteroscopic tubal cannulation include
active infection, heavyuterine bleeding, potential pregnancy,and
uterine malignancy. Patients with known allergy or adverse reaction to contrast dye used to establish patency should be appropriately counseled. The potential complications associated with
the procedure are listed in Table 8.4.2. Reversal of the occlusion
in the cornua may improve fertility sufficiently to result in an
ectopic pregnancy. The catheter or wire guide may dissect or perforate the tubal wall. A dissection of the tubal wall may lead to
extravasation of the contrast material or dye.
Figure 8.4.2. Appearance of the tube after successful cannulation of
the tube shows distal tubal disease.
Patients, no./
Studies, no.
Microsurgery 175/5 83 (47.4) 7 (4) 13
Fluoroscopy
Hysteroscopy 133/4 22 (48.9) 3 (6.7) 2
SAB, spontaneous abortion. See Honore et al. for source data. [1]
∗
≥20 weeks gestation.
†
High-success group.
†
163/4 47 (28.8) 11 (6.7) 4
Ongoing,
no. (%)
∗
SAB, no.
(%)
Ectopic,
no. (%)
(7.4)
(2.4)
(4.4)
Table 8.4.2: Adverse Effects of Hysteroscopic
Tubal Cannulation
Damage to normal tube
Dissection
Perforation
Pain
Ectopic pregnancy
The standard cannulation set usedistheNovycornualcannulation set. The tubal cannulation techniquewasdescribedbyNovy
and colleagues.[12] The procedureis carried out using astandard
5-mm hysteroscope with anoperativechannel. The procedure for
fluoroscopic cannulation is accomplished using the same principle. The set has two separate catheter systems. The first is a 5F
catheter, called the introducing catheter, with two ports: one for
the introduction of the obturator and the other for the introduction of the second catheter, which is 3F.
Knowledge of the anatomy of the intramural portion of the
tube is important to properly carry out the procedure. The intramural portion ofthe uterine tubes is typically 1 to 2 cm in length.
Three patterns have been described.[13] The segment may be
straight, curved, or tortuous. The course of the tube is not necessarily symmetrical in the patient, and each intramural portion may be different. The most frequent pattern is tortuous followed by straight and curved. The direction of the mucosal folds
is toward the uterine tube. Introduction of the catheter should
therefore follow this direction. There is a potential sphincter at
this junction that is probably composed of the uterine smooth
layers.Thiscan close the tube, as evidenced byspasmduringHSG.
Preoperatively, the patient may require something to facilitate cervical dilatation, such as the (off-label) use of misoprostol
or insertion of laminaria tents. A preoperative antibiotic, such
as a cephalosporin, should be given. A laparoscopy is performed
simultaneously,and a “picture-in-picture” view isbrought on the
monitor so that the laparoscopic view of the fimbriated end of
the tube and the hysteroscopic view of uterine cavity are simultaneously visualized (Figure 8.4.3). If the patient is shown to
have distal tubal disease as well, the procedure is terminated.
164 — Tommaso Falcone and Jeffrey M. Goldberg
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Figure 8.4.3. The outer catheter has been introduced through the hysteroscope into the uterine cavity. The distal transparent end is curved
and is brought up to the tubal ostia.
Uterine tubeswith proximal and distal disease should be referred
for IVF. If the distal end of the tube is adequate, the next step is
to inject dilute dye through a uterine manipulator to confirm the
cornual obstruction. If confirmed, the hysteroscopic procedure
can proceed.
The introducing catheter is inserted into the operating channel of the hysteroscope. An angled lens is typically used. The
obturator is then removed and the catheter occluded. The tip of
this catheter is curved and wedged against the tubal ostium (Figure 8.4.3). Dilute indigo carmine dye may be injected. If dye is
seen coming from the tube, patency is confirmed and the procedure is finished. If no dye is seen, the inner catheter will be
introduced to cannulate the tube.
The inner catheter has 1-cm markings. Theguidewireisintroduced through this catheter,whichhas a special adaptor for securing the wire. The wire is positioned at the tip of this catheter
Figure 8.4.4. The inner catheter with markings is seen through the
distal transparent sheath.
and the adaptor tightened. The catheter and wire are introduced
through the side of the introducing catheter up to the tip. Both
catheters and the guidewire should be flush. The cannulation
of the tube occurs first with the guidewire, and then the inner
catheter is brought over it. The guidewire is advanced slowly
through the uterotubal junction into the intramural portion of
the tube into the isthmic portion (Figure 8.4.4). This can be seen
by laparoscopy. Thecatheter is thenadvanced over the guidewire.
The distanceintothetubecanbemeasuredbythemarkingsonthe
catheter. The guidewire is removed and the dilute dye is injected
under laparoscopic observation. If dye isobserved, theprocedure
is terminated. If there is resistance to passage of the guidewire or
catheter, an attempt is made to mobilize the tube laparoscopically. If unsuccessful, the procedure is terminated. If the cause of
the obstruction is not apparent, the next step is to counsel the
patient regarding tubal surgery or IVF.
REFERENCES
1. Honore GM, Holden AE, Schenken RS. Pathophysiology and
management of proximal tubal blockage. Fertil Steril. 1999;71:
785–795.
2. Hedon B, Dechaud H, Boulot P, Laffargue F. Critical evaluation of
the fallopian tube. In: Kempers RD, Cohen J, Haney AF, Younger
BJ, eds. Fertility and Reproductive Medicine. Amsterdam: Elsevier
Science; 1998:61–70.
3. Evers JL, LandJA,Mol BW. Evidence-based medicinefordiagnostic
questions. SemReprodMed. 2003;21:9–15.
4. Dessole S, Meloni GB, Capobianco G, Manzoni MA, Ambrosini
G, Canalis GC. A second hysterosalpingography reducesthe use of
selective technique for treatment of a proximal tubal obstruction.
Fertil Steril. 2000;73:1037–1039.
5. Mol BW, Collins JA, Burrows EA, Van DV, Bossuyt PM. Comparison of hysterosalpingography and laparoscopy in predicting
fertility outcome. Hum Reprod. 1999;14:1237–1242.
6. Sulak PJ, Letterie GS, Coddington CC, Hayslip CC, Woodward
JE, Klein TA. Histology of proximal tubal occlusion. Fertil Steril.
1987;48:437–440.
7. Platia MP, Krudy AG. Transvaginal fluoroscopic recanalization of a proximally occluded oviduct. Fertil Steril. 1985;44:
704–706.
8. Sulak PJ, Letterie GS, Hayslip CC, Coddington CC,Klein TA. Hysteroscopic cannulation and lavage in the treatment of proximal
tubal occlusion. Fertil Steril. 1987;48:493–494.
9. Pinto AB, Hovsepian DM, Wattanakumtornkul S, Pilgram TK.
Pregnancy outcomes after fallopian tube recanalization: oil-based
versus water-soluble contrast agents. J Vasc Intervent Radiol.
2003;14:69–74.
10. Letterie GS, Sakas EL. Histology of proximal tubal obstruction in
cases of unsuccessful tubal canalization. Fertil Steril. 1991;56:831–
835.
11. Dessole S, Farina M, Rubattu G, Cosmi E, Ambrosini G, Battista
NG. Sideeffects and complications ofsonohysterosalpingography.
Fertil Steril. 2003;80:620–624.
12. Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J. Diagnosis
of cornealobstruction by transcervical fallopiantube cannulation.
Fertil Steril. 1988;50:434–440.
13. Rozewicki S, Radomska A, Kurzawa R. Relation between anatomical courses of the intramural portions of the uterine tubes and
pelvic endometriosis. Fertil Steril. 2005;85:60–66.
Section 8.5. Hysteroscopic Sterilization
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Stephanie N. Morris and Keith Isaacson
Tubal sterilization is the most common form of birth control
used by women in the United States.[1] About half of all tubal
sterilizations are performed as interval procedures (unrelated to
pregnancy), the vast majority (89%) of which are completed
laparoscopically.[1,2] Although laparoscopictubal ligation issafe
and effective, it requires general anesthesia and entry into the
abdominal cavity, both of which are associated with rare but
potentially serious complications.
Transcervical or hysteroscopic sterilization can offer patients
an alternative option for permanent sterilization. Despite multiple efforts over the past 30 years, acceptable methods of transcervical permanent contraception have only recently been developed. Previous strategies for hysteroscopic sterilization have
included mechanical tubal occlusive devices or plugs, intratubal
or intrauterine sclerosing agents, and destruction of a portion of
the fallopian tube with thermal energy.[3] Until recently, these
attempts have been unsuccessful because of unacceptably high
rates of pregnancy,ectopic pregnancy,expulsionofdevices, infection, and perforation.
New hysteroscopicsterilization techniques offer effective permanent contraception without the discomfort, associated recovery time, and risks of a laparoscopic procedure with general anesthesia. Furthermore, hysteroscopic sterilization is an alternative
for women in whom laparoscopy is especially difficult or contraindicated, such as women with severe cardiopulmonary disease, a history of prior abdominal or pelvic surgery with known
extensive adhesions, or obesity.
Currently, there is only one hysteroscopic sterilization device
approved by the U. S. Food and Drug Administration (FDA):
Essure (Conceptus, San Carlos, CA). The Essure device has
proved to be a highly effective permanent birth control option,
with a low rate of associated adverse outcomes and high patient
acceptance.[1,4–6] There are several other technologies currently undergoing initial clinical trials, including the Ovion system (American Medical Systems, Minnetonka, MN) and Adiana
(Cytyc, Marlborough, MA).
ESSURE
Description and Mechanism of Action
The Essure system is the first hysteroscopic tubal sterilization
device to be approved by the FDA, in 2002. Using a transvaginal approach, one micro-insert is placed in the proximal portion
of each fallopian tube.[7] When the micro-insert is released, it
expands and anchors itself in the fallopian tube. Over time, the
micro-insert elicits a benign inflammatory response, which ultimately leads to tubal occlusion and permanent contraception.
As described in the package insert [7], the Essure microinsert consists of a stainless steel inner coil and a nickel titanium
(nitinol)-expanding outer coil. The inner coil attaches the device
to the delivery wire that is used for placement of the device. The
outercoilexpandsupondeploymentandanchorsthedeviceinthe
fallopian tube. Polyethylene terephthalate (PET) fibers are wound
in and aroundtheinnercoil.ThePETfibers,whichhavebeenused
in other medical devices, produce an immediate local inflammatory response characterized by macrophages, mononuclear
cells, fibroblasts, foreign body giant cells, and plasma cells.[8,9]
This inflammatory response peaks between 2 and 3 weeks and
lasts approximately 10 weeks.[8,10] The resulting fibrosis causes
occlusion of the fallopian tubesand results in permanent anchoring of the device and contraceptive effects.
During insertion, the micro-insert is maintained in the
wound-down position through the use of a release catheter that
is sheathed by a hydrophilic delivery catheter to help with tubal
placement (Figure 8.5.1).[6] The outer coil expands from 4.0 cm
in length and 0.8 mm in diameter in the wound-down position
to 1.5 to 2.0 mm in diameter when released from the delivery
wire, depending on the diameter and shape of the fallopian tube
(Figure 8.5.2).[7]
Ideally, the micro-insert should span the uterotubal junction
(UTJ), defined as the portion of the fallopian tube just as it exits
the uterus (Figure 8.5.3). In this position, the springlike release
of the device and expansion of the outer coil lead to anchoring
during the acute phase of device implantation.[7] The PET fibers
then elicit a chronic inflammatory and fibrotic response, leading
to tissue ingrowth into the device and complete occlusion of the
fallopian tube lumen, resulting in permanent retention of the
micro-insert and the contraceptive effects.[9]
Clinical Use and Technique
There are several clinical considerations to keep in mind when
performing an Essure placement. The Essure system is designed
as an interval tubal sterilization technique. Therefore, the patient
should be at least 6 weeks post delivery or termination.[7]
Ideally, the procedure should be timed with thepatient’s menstrual cycle. Insertion is recommended during the early proliferative phase of the menstrual cycle to improve visualization of
the fallopian tube ostia and prevent placement in a luteal phase
pregnancy.[7] Alternatively, the patient can be pretreated with
oral contraceptive pills or Depo Provera (Pfizer) to help thin the
endometrial lining and avoid placement in an undiagnosed pregnancy. As reported in a study by Kerin et al. [4], the time of the
menstrual cycle during which the procedure was performed did
not affect success rates of bilateral device placement. However, it
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166 — Stephanie N. Morris and Keith Isaacson
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Figure 8.5.1. Essure micro-insert in wound-down configuration. The
Essure micro-insert, when attached to the delivery wire in a wounddown configuration, is 4 cm in length and 0.8 mm in diameter. Used
with permission from Conceptus.
was easier to see the tubal opening before ovulation, when the
endometrial lining was thinner.[4]
Several measures should be taken to avoid placement during an undiagnosed pregnancy and to prevent unplanned pregnancy after insertion. First, apregnancy test shouldbe performed
within 24 hours before the procedure. The combination of a
pregnancy test and placement of the device during the first half
of the cycle should help avoid an undetected luteal phase pregnancy.Finally, the patient should be advised to usecontraception
for 3 months after the procedure, until complete tubal occlusion and proper micro-insert placement can be verified by a
hysterosalpingogram.[7]
Essure placement can be performed in the office or as outpatient surgery. The majority of these procedures can be performed
with local anesthesia alone.[4,5,11] In a recent multicenter study
of more than 100 women, 81% underwent the procedure with
local paracervical block without additional intravenous sedation
and tolerated the procedure well.[11] It is the decision of the
patient and provider whether to use anesthesia, such as intravenous conscious sedation, in addition to a paracervical block.
If only a paracervical block is used, an oral anxiolytic may be
administered to the patient before the procedure. Our preferred
technique for paracervical block involves injecting a total of 20
mL of 1% lidocaine without epinephrine, with 10 mL each at the
4 and 8 o’clock positions.[12] After the paracervical block is performed, itis important to wait several minutes before starting the
procedure to give enough time for the anesthetic to take effect.
Regardless of the anesthetic choice, a nonsteroidal antiinflammatory drug (NSAID) should be given 30 to 60 minutes
before the procedure. Not only does this provide additional pain
relief, but administration of NSAIDs before the procedure also
increases the chance of successful cannulation of the fallopian
tube and placement of the micro-inserts.[5] It is thought that
preprocedural NSAIDs decrease the chance of tubal spasm, thus
increasing the rate of successful placement.
To perform the insertion of the micro-inserts, the patient is
placed inthe semidorsal lithotomy position, using the examtable
stirrups if the procedure is performed in the office. An opensided speculum is placed in the vagina, the cervix is prepped
with Betadine, and aparacervical block is performed. The microinserts are placed using the Essure delivery system through a
small-caliber hysteroscope (usually 5-mm outer diameter) with
Figure 8.5.3. Diagram of the UTJ. The micro-insert should span the
UTJ, defined as the portion of the fallopian tube just as it exits the
uterus. In this location, the coils span the intramural and proximal
isthmic portions of the fallopian tube. The device is placed far enough
into the tube to prevent expulsion during uterine contractions during
menses but still has a portion trailing into the uterine cavity. The outer
diameter of the coils that trail into the uterus is larger than that of
the coils in the fallopian tube, which helps anchor the device. The
UTJ is most consistently the narrowest portion of the fallopian tube,
which further aids in anchoring thedevice. Used with permission from
Conceptus.
a continuous-flow system and an operating channel of at least 5F
(1.7-mm internal diameter) (Figure 8.5.4). The hysteroscope is
placed under direct visualization through the cervix and into the
uterine cavity without prior cervical dilation. Normal saline is
used during placement of the hysteroscope to aid in visualization
as well as to gently dilate the cervical canal and uterus. An initial
attempt to pass the hysteroscope may be made without the use of
a tenaculum. If the hysteroscope is not passed easily, a tenaculum
is placed to aid in the insertion, and if needed, cervical dilation
may be performed.
Normal saline is used to distend the uterine cavity. Saline
that is body temperature and introduced “under gravity” is recommended tohelp minimize patient discomfort. To achieveadequate distention, the saline bag must be approximately 120 to
140 cm above the uterus. Pressure bags may also be used to help
maintain uterine distention if there is cervical leakage due to a
patulous cervix.[7] Both tubal ostia should be visualized before
placement of the device. A 12
to help with visualization of the ostia as well as with cannulation
of the fallopian tube (Figure 8.5.5). The 12
◦
or 30◦hysteroscope may be used
◦
scope is helpful in
cases of more-forward tubal ostia and in placement of the device,
Figure 8.5.2. Expanded Essure device. The Essure micro-insert
expands to a diameter of 1.5 to 2 mm, depending on the diameter
and shape of the surrounding fallopian tube. Used with permission
from Conceptus.
Figure 8.5.4. The Essuredelivery systemand hysteroscopicequipment.
The Essure delivery system with the micro-insert attached to the delivery catheter. Used with permission from Conceptus.
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