Amenorrhoea secondary to endometrial ablation and Asherman's syndrome following uterine artery embolization

Reducing radicality in fertility-sparing surgery is associated with improved in vitro fertilization outcome in early-stage cervical cancer: A national retrospective study

OBJECTIVE

Fertility-sparing surgery (FSS) aims to achieve oncological outcomes that are non-inferior to radical treatment while preserving fertility and optimizing reproductive results. This study assesses in vitro fertilization (IVF) outcomes in early-stage cervical cancer survivors following FSS, comparing radical and non-radical approaches.

METHODS

This retrospective analysis used data from Hungary's National Health Insurance Fund (2004-2022) on patients who underwent IVF treatment following FSS for early-stage cervical cancer at ten Hungarian fertility clinics. Patients were classified into radical and non-radical surgical groups, with the uterine arteries being spared in the non-radical procedures. RStudio (R software version: 4.2.2) was used for statistical analysis. Student's t-test was used to compare group means, and Fisher's exact test was applied to assess independence and distributions between categorical variables, and to estimate odds.

RESULTS

The study analyzed data from 122 IVF treatment cycles involving 36 patients. The non-radical group had a significantly higher live birth rate (83%, 5/6 compared to the radical group (17%, 5/30). Additionally, the non-radical group had a significantly higher implantation rate and cumulative live birth rate per oocyte retrieval (37%, 7/19 and 55%, 6/11 respectively) compared to the radical group (8%, 12/148 and 6%, 5/80 respectively).

CONCLUSION

This is the largest study to evaluate IVF outcomes in young cervical cancer survivors who have undergone FSS. The findings suggest that less radical procedures are associated with significantly better IVF outcomes. These results emphasize the importance of considering oncological safety and reproductive outcomes together when choosing FSS for early-stage cervical cancer patients. It also highlights the reproductive benefits of performing less radical surgery.

Current evaluation of amenorrhea: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee Opinion is to provide clinicians with principles and strategies for the diagnostic evaluation of patients presenting with primary or secondary amenorrhea. This revised document replaces the Practice Committee Document titled "Current evaluation of amenorrhea," last published in 2008 (Fertil Steril 2008;90:S219-25).

Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center

OBJECTIVE

To evaluate effectiveness and safety of UFE as alternative to surgery, in treatment of uterine fibromatosis.

METHODS/MATERIALS

255 patients (aged 26-55) with symptomatic UF, indication for surgery, followed in our center (2000-2014), single or multiple fibroids, pain and/or functional/compressive disorders, underwent embolization: injection of PVA particles (150-900 μm) from distal portion of uterine arteries (ascending section). Primary end-point: flow-stop distally to injection site, disappearance of lesion design, preservation of flow in main trunk of UA. Secondary end-point: control of pain and functional/compressive disorders during follow-up (2-7 years).

RESULTS

Procedure was performed bilaterally in 250 patients (98%). Mean duration: 47 min (average fluoroscopy: 10:50 min). Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h). Follow-up at 2 years: resolution of menstrual disorders in 78% of patients and improvement in 14%; pain disappeared in 66%; significant improvement of menstrual flow and HCT/HB levels, decrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. Recurrence in 18 patients.

CONCLUSIONS

UFE represents an excellent alternative to surgical treatment: it is safe, tolerable and effective both in short and long term, with evident advantages in economic and social terms.

A novel resorbable embolization microsphere for transient uterine artery occlusion: a comparative study with trisacryl-gelatin microspheres in the sheep model

PURPOSE

To evaluate angiographic recanalization, inflammatory reaction, and uterine damage after sheep uterine artery embolization (UAE) with a novel calibrated resorbable embolization microsphere (REM) and compare the results with control nonresorbable microspheres.

MATERIALS AND METHODS

Six hormonally artificially cycled sheep underwent bilateral UAE until stasis with either REM or trisacryl-gelatin microspheres (TGMS). At 7 days, control angiograms were obtained to assess the residual vascularization at arterial and parenchymal phases. The animals were then sacrificed for analysis of the presence of microspheres, inflammatory foreign body reaction, and surface areas of uterine damage.

RESULTS

Mean volume of microspheres injected per uterine artery (UA) or per animal did not differ between groups. At day 7, the flow was normal for six of six UAs that received embolization with REM versus only three of six UAs with TGMS (P = .0455, χ(2) test). Uterine parenchymography showed no defects in six UAs in the REM group versus five defects in six UAs in the TGMS group (P = .0060, χ(2) test). No REM or residual fragments of microspheres were observed on histologic analysis. TGMS were observed in tissues and accompanied by a mild inflammatory response. Necrosis rates were not significantly different between the two products, either in endometrium (REM 23.5% ± 28.8% [median 8.1%] vs TGMS 21.8% ± 23.7% [median 14.6%]) or in myometrium (REM 8.2% ± 22.7% [median 0.0%] vs TGMS 8.8% ± 20.8% [median 0.9%]). Endometrium alteration rate was lower with REM than with TGMS (39.7% ± 25.7% [median 34%] vs 60.6% ± 27.1% [median 71%]; P = .0060, Mann-Whitney test). Myometrium alteration rates were not significantly different between REM (45.7% ± 37.1% [median 63.0%]) and TGMS (37.8% ± 34.0% [median 19.1%]).

CONCLUSIONS

At 1 week after sheep UAE with REM, the recanalization was complete, the microspheres were completely degraded, and there was no remnant inflammatory response.

A matched cohort study comparing the outcome of intrauterine adhesiolysis for Asherman's syndrome after uterine artery embolization or surgical trauma

STUDY OBJECTIVE

To compare the outcome of hysteroscopic adhesiolysis in women who had Asherman's syndrome after uterine artery embolization (UAE) with those who had Asherman's syndrome caused by surgical trauma.

DESIGN

A retrospective cohort study matched for age and intrauterine adhesion score (Canadian Task Force classification II-2).

SETTING

A tertiary hysteroscopic center in a teaching hospital.

PATIENTS

Nineteen women with Asherman's syndrome after UAE and 57 women with Asherman's syndrome caused by surgical trauma.

INTERVENTIONS

Hysteroscopic adhesiolysis was followed by a second-look hysteroscopy 1 month later. The scoring system proposed by the American Fertility Society was used to evaluate intrauterine adhesion during hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

In the UAE group, only 42.1% of women experienced improvement in menstruation defined as a subjective increase in menstrual flow after surgery, which was significantly lower than that of 86.0% observed in the non-UAE group. In the UAE group, the reduction of the American Fertility Society (AFS) score after intrauterine adhesiolysis was 30%, which was significantly lower than that of 80% in the non-UAE group. The pregnancy rate and live birth rate in the UAE group (5% and 0%, respectively) were significantly lower than the corresponding rates in the non-UAE group (33% and 25%, respectively).

CONCLUSION

The outcome of hysteroscopic adhesiolysis in women with Asherman's syndrome after UAE was worse than in women with Asherman's syndrome caused by surgical trauma.

Uterine fibroids: pathogenesis and interactions with endometrium and endomyometrial junction

Uterine leiomyomas (fibroids or myomas) are benign tumors of uterus and clinically apparent in a large part of reproductive aged women. Clinically, they present with a variety of symptoms: excessive menstrual bleeding, dysmenorrhoea and intermenstrual bleeding, chronic pelvic pain, and pressure symptoms such as a sensation of bloatedness, increased urinary frequency, and bowel disturbance. In addition, they may compromise reproductive functions, possibly contributing to subfertility, early pregnancy loss, and later pregnancy complications. Despite the prevalence of this condition, myoma research is underfunded compared to other nonmalignant diseases. To date, several pathogenetic factors such as genetics, microRNA, steroids, growth factors, cytokines, chemokines, and extracellular matrix components have been implicated in the development and growth of leiomyoma. This paper summarizes the available literature regarding the ultimate relative knowledge on pathogenesis of uterine fibroids and their interactions with endometrium and subendometrial myometrium.

Review of intrauterine adhesions

This article has been produced to review the literature on symptomatic and asymptomatic intrauterine adhesions. Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Current Contents, and EMBASE were searched using the Medical Subject Headings (MeSH), including all subheadings, and the keywords "Asherman syndrome," "Hysteroscopic lysis of adhesions," "Hysteroscopic synechiolysis," "Hysteroscopy and adhesion," "Intrauterine adhesions," "Intrauterine septum and synechiae," and "Obstetric outcomes after intrauterine surgery." The vast majority of evidence in the literature consists of uncontrolled case series, with only intrauterine adhesion barriers being assessed in a randomized controlled format. This article reviews epidemiology, pathologic features, classification systems, and treatments. Seven classification systems are described, with no universal acceptance of any one system and no validation of any of them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical treatments having no role in management. There is a wide range of treatment techniques with no controlled comparative studies, and assessments are descriptive and report fertility and menstrual outcomes, with more severe adhesions having the worst clinical outcomes. One of the most important features of treatment is prevention of recurrence, with the best available evidence demonstrating that newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions.

Proinflammatory and profibrotic mediators: principal effectors of leiomyoma development as a fibrotic disorder

Leiomyomas are believed to derive from the transformation of myometrial smooth muscle cells/connective tissue fibroblasts. Although the identity of the molecule(s) that initiate such cellular transformation and orchestrate subsequent growth is still unknown, conventional evidence indicates that ovarian steroids are essential for leiomyoma growth. Ovarian steroid action in their target cell/tissue is mediated in part through local expression of various growth factors, cytokines, and chemokines. These autocrine/paracrine molecules with proinflammatory and profibrotic activities serve as major contributing factors in regulating cellular transformation, cell growth and apoptosis, angiogenesis, cellular hypertrophy, and excess tissue turnover, events central to leiomyoma growth. This review addresses the key regulatory functions of proinflammatory and profibrotic mediators and their molecular mechanisms, downstream signaling that regulates cellular events that result in transformation, and commitments of specific cells into forming a cellular environment with a possible role in development and subsequent growth of leiomyomas.

Asherman syndrome--one century later

OBJECTIVE

To provide an update on the current knowledge of Asherman syndrome.

DESIGN

Literature review.

SETTING

The worldwide reports of this disease.

PATIENT(S)

Patients with Asherman syndrome who presented with amenorrhea or hypomenorrhea, infertility, or recurrent pregnancy loss.

INTERVENTION(S)

Hysteroscopy and hysteroscopic surgery have been the gold standard of diagnosis and treatment respectively for this condition.

MAIN OUTCOME MEASURE(S)

The etiology, pathology, symptomatology, diagnosis, treatment, and reproductive outcomes were analyzed.

RESULT(S)

This syndrome occurs mainly as a result of trauma to the gravid uterine cavity, which leads to the formation of intrauterine and/or intracervical adhesions. Despite the advances in hysteroscopic surgery, the treatment of moderate to severe Asherman syndrome still presents a challenge. Furthermore, pregnancy after treatment remains high risk with complications including spontaneous abortion, preterm delivery, intrauterine growth restriction, placenta accrete or praevia, or even uterine rupture.

CONCLUSION(S)

The management of moderate to severe disease still poses a challenge, and the prognosis of severe disease remains poor. Close antenatal surveillance and monitoring are necessary for women who conceive after treatment.

Uterine artery embolization and future fertility potential

The growing body of evidence concerning the safety and efficacy of uterine artery embolization (UAE) has led to increasing confidence amongst gynecologists and interventional radiologists that UAE can be used safely to treat women with symptomatic fibroids. UAE is clearly preferable for certain subgroups of patients, for example those with increased risks of complications of general anesthesia, those with religious objection to blood transfusion and those wishing to avoid surgical risk. This review of the available literature demonstrates the paucity of information concerning safety and efficacy of UAE for those wishing to conceive. Case reports and series are largely positive. However, there are continuing concerns over the effects of UAE on ovarian and uterine function, and on subsequent pregnancy outcome. More long-term data and randomized controlled trials are required to address these issues. Women who undergo embolization should be told that the effects on pregnancy and the resulting child are uncertain and that there may be long-term implications for the health and development of the offspring. Hence, it is inadvisable to try to conceive following the procedure. Given the available evidence, concern must remain that UAE may lead to significant damage to fertility, with higher risk of miscarriage and adverse pregnancy outcome when compared with open or laparoscopic myomectomy.

Magnetic resonance-guided focused ultrasound surgery for uterine fibroids: relationship between the therapeutic effects and signal intensity of preexisting T2-weighted magnetic resonance images

OBJECTIVE

This study was undertaken to clarify the relationship between the signal intensity of T2-weighted magnetic resonance images and the therapeutic effect of magnetic resonance-guided focused ultrasound surgery (MRgFUS) on uterine fibroids.

STUDY DESIGN

Ninety-five fibroids in 63 patients were classified into 3 types based on the signal intensity of T2-weighted magnetic resonance images as follows: type 1, low intensity; type 2, intermediate intensity; type 3, high intensity. The treated area ratio of MRgFUS and the volume reduction ratio 6 months after treatment were used as the indices of therapeutic effect.

RESULTS

The treated area ratio of type 3 fibroids was the lowest among the 3 types (P < .01). The volume reduction ratio correlated with the treated area ratio (r = 0.64; P < .01).

CONCLUSION

The efficacy of MRgFUS correlates with the signal intensity of T2-weighted magnetic resonance images. Type 1 and type 2 fibroids are suitable candidates for MRgFUS, whereas type 3 fibroids are not.

[Embolization of uterine arteries for uterine fibroids: state-of-the-art]

Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.

Uterine artery embolization: state of the art

Since the first report in 1995, there has been rapid expansion of uterine artery embolization as a therapy for symptomatic uterine fibroids. The published literature and clinical experience show that this procedure is safe and effective. This article discusses the history of the procedure, current issues in procedure technique, and the state of the literature regarding outcomes of embolization. Current and future research topics also are discussed.