Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids

European Society for Gynaecological Endoscopy (ESGE) Good Practice Recommendations on surgical techniques for removal of fibroids: part 1 abdominal (laparoscopic and open) myomectomy

Uterine fibroids are the most common benign tumours of the female reproductive tract and can cause a range of symptoms including abnormal uterine bleeding, pain, pressure symptoms and subfertility. Surgery may be required for some symptomatic fibroids via abdominal or transvaginal routes. The European Society for Gynaecological Endoscopy Uterine Fibroids Working Group developed recommendations based on the best available evidence and expert opinion for the surgical treatment of uterine fibroids. In this first part of the recommendations, abdominal approaches to surgical treatment of fibroids including laparoscopic, robot- assisted and open myomectomy are described.

Construction and evaluation of intrauterine adhesion model in rats by different methods of mechanical injury

PURPOSE

The study aimed to establish a stable and effective animal model for the experimental study of intrauterine adhesion (IUA) by evaluating various mechanical injury methods.

METHODS

A total of 140 female rats were divided into four groups according to the extent and area of endometrial injury: group A (excision area: 2.0 × 0.5 cm²), group B (excision area: 2.0 × 0.25 cm²), group C (endometrial curettage) and group D (sham operation). On the 3rd, 7th, 15th and 30th day after the operation, the tissue samples of each group were collected, and the uterine cavity stenosis and histological changes were recorded by HE and Masson staining. Immunohistochemistry of CD31 was applied to visualize microvessel density (MVD). The pregnancy rate and the number of gestational sacs were used to evaluate the reproductive outcome.

RESULTS

The results showed that endometrium injured by small-area endometrial excision or simple curettage could be repaired. The ratio of fibrosis in groups A and B was higher than that in groups C and group D 30 days after modeling (P < 0.001). The number of endometrial glands and MVD in group A was significantly lower than those in groups B, C and D (P < 0.05). The pregnancy rate in group A was 20%, which was lower than that in groups B (33.3%), C (89%) and D (100%) (P < 0.05).

CONCLUSION

Full-thickness endometrial excision has a high rate of success in constructing stable and effective IUA models in rats.

Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas

PURPOSE

To evaluate the frequency of intrauterine adhesion (IUA) after hysteroscopic myomectomy, and to analyze the association of IUA and the location of submucous myomas and the use of postoperative barrier (POB).

METHODS

Hysteroscopic myomectomy was performed in 217 patients with submucous myomas. The retrospective investigation was performed, and the cases were divided into three groups: cases with solitary submucous myoma (SSM; group 1), cases with apposing submucous myomas (ASMs; group 2) and cases with submucous myomas that were far from each other or not in apposition to one another (not apposing submucous myomas: NASMs; group 3). As POB, intrauterine device with oxidized regenerated cellulose and silicon sheet was inserted immediately after surgery.

RESULTS

IUA formation after hysteroscopic myomectomy was more frequent in group 2 than groups 1 and 3 (p = 0.03 and 0.01, respectively), despite the higher rates of POB use (p = 0.02). There was no significant difference in IUA formation in cases with POB between each group (p = 0.06 and 0.21, respectively). But in cases without POB, group 2 showed higher rates of IUA formation than group 1 (p = 0.04) and group 3 (p = 0.03). Multivariable analysis for IUA formation demonstrated that ASMs were a risk factor of IUA (hazard ratio [HR] = 27.9, p < 0.01), and the use of POB was a prognostic factor for reduction of IUA formation (HR = 0.08, p < 0.01).

CONCLUSION

ASMs appear to be a risk factor for IUA formation. The use of POB may be associated with preventing IUA formation after hysteroscopic myomectomy.

Post-surgical Intrauterine Adhesions After Hysteroscopic Myomectomy Using the Myoma Pseudocapsule Preservation Technique Evaluated bv Second-look Hysteroscopy: A Retrospective Comparative Study

STUDY OBJECTIVE

To analyze the frequency and risk factors of post-surgical intrauterine adhesions (IUA) using second-look hysteroscopy (SLH) in patients undergoing hysteroscopic myomectomy carried out by the myoma pseudocapsule preservation technique for submucosal myoma.

DESIGN

Retrospective cohort study.

SETTING

University hospital from January 2017 to December 2019.

PATIENTS

A total of 124 patients underwent hysteroscopic myomectomy and SLH.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Surgical duration, intraoperative blood loss, number of enucleated myomas, volume of specimen, post-surgical IUA evaluated by SLH. Post-surgical IUA were found in 5/124 cases (4.0%) at SLH. There were no cases of intrauterine adhesion formation in cases in which a single myomas was resected (0/83 cases, 0%), all cases were multiple myomas (5/41 cases, 12.2%), and significantly occurred more frequently in cases of multiple myoma (p = 0.003). Univariate analyses showed that the IUA group contained a significantly larger number of enucleated uterine myoma (p < 0.001), required a longer operation (p = 0.003), displayed an increased volume of intraoperative bleeding (p = 0.007), and the heavier the specimen, the greater the number of patients that had inserted an IUD than the group that did not display post-surgical IUA. Multivariate logistic regression analysis of the risk factors of post-surgical IUA showed that the number of enucleated myomas was strongly associated with IUA (odds ratio 1.45,95% confidence interval 1.06-1.97).

CONCLUSION

The frequency of post-surgical IUA after hysteroscopic myomectomy was high in cases of multiple myoma and may be a risk factor. SLH should be actively pursued in cases where the patient desires to bear children, and informed consent should be attained before carrying out surgery.

Prevalence of intrauterine adhesions after myomectomy: a prospective multicenter observational study

OBJECTIVES

To evaluate intrauterine adhesion formation after laparoscopic and laparotomic myomectomy.

DESIGN

Prospective, multicenter, observational study (ClinicalTrials.gov ID: NCT04030273).

METHODS

We included patients after laparotomic and laparoscopic myomectomy. All patients underwent post-surgical diagnostic hysteroscopy, after three months. The intrauterine adhesion rate and associated factors were investigated.

RESULTS

Between January 2020 and December 2020, 38 and 24 consecutive patients underwent laparoscopic and laparotomic myomectomy, respectively. All diagnostic hysteroscopies were performed in the office setting without complications. Intrauterine adhesions were identified in 19.4% of women (95% CI of 9 - 29%). Factors univariately associated (p <0.2) with the presence of intrauterine adhesions after myomectomy were previous uterine surgery, the surgical approach (laparoscopic or laparotomic), the number of removed fibroids, the type and diameter of the largest myoma, and the opening of the uterine cavity. In the multivariable analysis, only the opening of the uterine cavity (OR 51.99; 95% CI, 4.53 - 596.28) and the laparotomic approach (OR, 16.19; 95% CI, 1.66 - 158.35) were independently associated with the identification of intrauterine adhesions after myomectomy.

LIMITATIONS

One of the main limitations of our study is that we used uterine manipulator only in laparoscopic group; in addition, we did not perform a pre-operative hysteroscopy to evaluate the rate of intrauterine adhesions potentially present even before the myomectomy.

CONCLUSIONS

The prevalence of intrauterine adhesions after three months from surgery was significantly associated with the opening of the uterine cavity and the laparotomic approach.

Hysteroscopic findings after laparoscopic and open myomectomy with or without uterine cavity breach: historical cohort study

INTRODUCTION

The aim of this study was to evaluate hysteroscopic findings after laparoscopic and laparotomic myomectomy with a focus on the presence of postoperative intrauterine adhesions in groups of patients with and without perioperative uterine cavity breach (UCB).

MATERIAL AND METHODS

This is a historical cohort study. Our database was searched to identify patients with UCB during myomectomy and matched the same number of patients after myomectomy without UCB to create a control group. All relevant data were retrieved from our medical records. In both groups, the results of follow-up hysteroscopy were analyzed.

RESULTS

Low prevalence of intrauterine adhesions after myomectomy was observed in only 3.5% of the 170 patients in our samples. No significant difference in the occurrence of synechiae between the patients with and without UCB was found (2 vs. 4, RR 0.5, 95% CI 0.1-2.7, p = .341), nor was the difference in other hysteroscopic findings. Follow-up hysteroscopy was performed with slender optics and expandable casing system without need of any anesthesia in 87.1% of cases.

CONCLUSIONS

According to our findings, the prevalence of post-myomectomy intrauterine adhesions after myomectomy is low. Our study did not demonstrate that UCB during myomectomy is a risk factor for the formation of intrauterine synechiae.

Uterine Fibroids and Infertility

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

Transcervical microwave ablation in type 2 uterine fibroids via a hysteroscopic approach: analysis of ablation profiles

Type 2 uterine fibroids are challenging to resect surgically as ≥ 50% volume of myoma lies within the myometrium. A hysteroscopic approach for ablating fibroids is minimally-invasive, but places a considerable burden on the operator to accurately place the ablation applicator within the target. We investigated the sensitivity of transcervical microwave ablation outcome with respect to position of the ablation applicator within 1 - 3 cm type 2 fibroids.Methods:A finite element computer model was developed to simulate 5.8 GHz microwave ablation of fibroids and validated with experiments inex vivotissue. The ablation outcome was evaluated with respect to applicator insertion angles (30°, 45°, 60°) , depth and offset from the fibroid center (±2 mm for 3 cm fibroid and ±1 mm for 1 cm fibroid) with 35 W and 15 W applied power for 3 cm and 1 cm fibroids, respectively. Power deposition was stopped when thermal dose of 40 cumulative equivalent minutes at 43 °C (CEM43) was accrued in adjacent myometrium.Results:Within the range of all evaluated insertion angles, depths and offsets, the ablation coverage was less sensitive to variation in angle as compared to depth and offset, and ranged from 34.9 - 83.6% for 3 cm fibroid in 140 - 400 s and 34.1 - 67.9% for 1 cm fibroid in 30 - 50 s of heating duration. Maximum achievable ablation coverage in both fibroid cases reach ∼ 90% if thermal dose is allowed to exceed 40 CEM43 in myometrium.Conclusion:The study demonstrates the technical feasibility of transcervical microwave ablation for fibroid treatment and the relationship between applicator position within the fibroid and fraction of fibroid that can be ablated while limiting thermal dose in adjacent myometrium.

Focus on the Primary Prevention of Intrauterine Adhesions: Current Concept and Vision

Intrauterine adhesion (IUA), and its severe form Asherman syndrome (Asherman’s syndrome), is a mysterious disease, often accompanied with severe clinical problems contributing to a significant impairment of reproductive function, such as menstrual disturbance (amenorrhea), infertility or recurrent pregnancy loss. Among these, its correlated infertility may be one of the most challenging problems. Although there are many etiologies for the development of IUA, uterine instrumentation is the main cause of IUA. Additionally, more complicated intrauterine surgeries can be performed by advanced technology, further increasing the risk of IUA. Strategies attempting to minimize the risk and reducing its severity are urgently needed. The current review will expand the level of our knowledge required to face the troublesome disease of IUA. It is separated into six sections, addressing the introduction of the normal cyclic endometrial repairing process and its abruption causing the formation of IUA; the etiology and prevalence of IUA; the diagnosis of IUA; the classification of IUA; the pathophysiology of IUA; and the primary prevention of IUA, including (1) delicate surgical techniques, such as the use of surgical instruments, energy systems, and pre-hysteroscopic management, (2) barrier methods, such as gels, intrauterine devices, intrauterine balloons, as well as membrane structures containing hyaluronate–carboxymethylcellulose or polyethylene oxide–sodium carboxymethylcellulose as anti-adhesive barrier.

Crosslinked Hyaluronic Acid Gels for the Prevention of Intrauterine Adhesions after a Hysteroscopic Myomectomy in Women with Submucosal Myomas: A Prospective, Randomized, Controlled Trial

Intrauterine adhesion (IUA), fibrosis, and scarring resulting from damage to the endometrium is a rare but serious clinical disease, contributing to a significant impairment of reproductive function. Uterine instrumentation, especially that of a hysteroscopic myomectomy, has become the main cause of IUA. Therefore, a prospective randomized controlled study to assess the effectiveness and short-term safety of the use of hyaluronic acid gels in the prevention of IUA after a hysteroscopic myomectomy and an evaluation of the characteristics of IUA observed at follow-up are presented here. A total of 70 patients were analyzed at the end of 16 March 2020. The results show that the incidence of IUA in women who underwent a hysteroscopic myomectomy is 21.4% (15/70), overall. Women treated with hyaluronic acid gels have a statistically significantly lower incidence of IUAs than non-treated women (12.8% vs. 39.1%, p = 0.012). In addition, women in the anti-adhesive gel treatment group had a dramatically reduced severity of IUA than women in the no-treatment group (p = 0.002). Further analysis shows that the International Federation of Gynecology and Obstetrics (FIGO) classification type and the use of anti-adhesive gels are independent factors associated with moderate and severe degrees of IUA formation. The results here highlight the significant therapeutic benefits of the application of hyaluronic acid gels in women undergoing a hysteroscopic myomectomy, especially for those patients with a uterine myoma classified as FIGO type 2. Since the risk of IUA after a hysteroscopic myomectomy is high, especially for patients who have not received prophylactic anti-adhesive gels, the application of hyaluronic acid gels as a prevention strategy is highly recommended. More studies are encouraged to confirm our observation.

Adhesions and Anti-Adhesion Systems Highlights

The peritoneal and intrauterine cavities are lined by fragile membranes with a high-wound healing capacity, e.g. repairing the endometrium in its cyclical "injury and scar-free repair process" during menstruation. However, peritoneal and intrauterine fibrosis and adhesions can develop after surgical trauma through activation of molecular, immune and genetic mechanisms. During procedures with a high-risk of adhesions, the use of new peritoneal and intrauterine conditions in combination with anti-adhesion substances are promising measures to preserve peritoneal and endometrial function and avoid the most common complication of gynecological surgery. Highlights of adhesions and anti-adhesion prevention techniques in laparoscopic, laparotomic and hysteroscopic surgeries are discussed in this paper. Unfortunately, evidence is lacking to prove the superiority of one technique over its counterparts in terms of postoperative adhesions, such as instrumentation, type of energy, distending media, and intracavitary pressure. Additionally, there is limited evidence about the efficacy and outcomes of techniques and adjuvant measures used during adhesiolysis. The definition of a universal intrauterine adhesions classification scheme as well as a prognostic scoring system to identify women at high risk of postoperative adhesions are necessary for advising those who could benefit the most of the use of antiadhesion barriers.

Synergistic regenerative effects of functionalized endometrial stromal cells with hyaluronic acid hydrogel in a murine model of uterine damage

Clinically intractable infertility and recurrent miscarriage due to irreversible endometrial damage need to be treated with biomaterial- and cell-based therapies. Some previous studies have reported on the efficacy of a collagen scaffold and/or bone marrow-derived mesenchymal stem cells. However, the functional differentiation of grafted cells was uncertain, and the time required for regeneration was long in these studies. Here, we show the synergistic regenerative effects of hyaluronic acid (HA) hydrogel with in vitro decidualized endometrial stromal cells (EMSCs) in a murine uterine infertility (synechiae) model. Decidualized EMSCs (dEMSCs) were encapsulated with HA hydrogel, combined with three different doses of fibrinogen/thrombin (5, 50, and 500 mIU/mL). The HA/fibrin gel showed biocompatibility when mixed with dEMSCs. The addition of thrombin enhanced gel formation (5 and 50 mIU/mL) and engraftment and enabled the effective release of adhesion molecules. Within two weeks, which is a short duration, treatment with hydrogel decreased the fibrous tissue and increased the thickness of the endometrium. The regenerated endometrium demonstrated functional recovery, as evidenced by the expression and secretion of molecules essential for embryonic implantation, such as Desmin, CD44, PECAM, and IGF-1. Transferred embryos successfully implanted and the normal development of implanted embryos (n = 37) were evaluated by co-localization of distinct markers of the three germ layers (Sox2, Nestin, Brachyury, AFP, and HNF4α). Live birth of offspring was achieved in the regenerated endometrium by HA hydrogel. Therefore, HA hydrogel-mixed dEMSCs can be an innovative treatment strategy with rapid recovery of endometrial damage and may also have therapeutic potential in intractable infertility or recurrent miscarriage. STATEMENT OF SIGNIFICANCE: Decidualized EMSCs (dEMSCs) encapsulated with HA hydrogel combined with fibrinogen/thrombin (50 mIU/mL) showed injectability and biocompatibility when mixed with dEMSCs. Hydrogel-encapsulated dEMSCs can be a useful treatment for damaged endometrium in short duration, with successful implantation and normal development in a murine model.

The Intrauterine Bigatti Shaver System: An Alternative Option for Focal Retained Products of Conception

The management of retained products of conception (RPOC) may be medical or surgical. Surgical options include blind curettage, ultrasound guided curettage, or curettage under direct vision via hysteroscopy. The definitive management of patients presenting with retained products of conception will depend on several factors: severity of bleeding, presence of hemodynamic instability or infection, and patient preference. Optimal management of retained products of conception should result in complete evacuation of the uterine cavity while minimizing endometrial trauma. This is of utmost importance in patients with reproductive desires. We report patients with RPOC managed via hysteroscopic removal using the Bigatti Morcellator. Both patients had complete evacuation of the visualized RPOC. The purpose of this paper is to present this approach as an effective management option particularly in patients with a history of subfertility and failed blind curettage.

Successful Pregnancies in Women with Diffuse Uterine Leiomyomatosis after Hysteroscopic Management Using the Hysteroscopy Endo Operative System

STUDY OBJECTIVE

To evaluate the feasibility, effectiveness, and reproductive outcome of hysteroscopic management using the Hysteroscopy Endo Operative system (HEOS) in patients with diffuse uterine leiomyomatosis (DUL).

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

PATIENTS

Eight women of reproductive age suffering from menorrhagia and anemia or infertility diagnosed with DUL by ultrasonography and hysteroscopy.

INTERVENTIONS

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS was performed to excise submucous myomas (including types 0, I, and II), leaving other intramural myomas in place. The fenestration method is used in electrical hysteroscopic myomectomy. Postoperative endometrial repair and synechiae, menstrual improvement, conception, and pregnancy were recorded.

MEASUREMENTS AND MAIN RESULTS

Two patients underwent a single hysteroscopic myomectomy, whereas 6 patients underwent 2 to 3 myomectomies. No complications were observed. The mean follow-up period was 39.13 ± 17.01 months (range, 21-67). The endometrium recovered 2 to 3 months after the initial surgery, and 100% improvement in menstruation was observed. Two patients had mild synechia after the first hysteroscopic surgery. Seven patients conceived spontaneously (postoperative pregnancy rate, 87.5%), 6 of whom had a full-term pregnancy. One patient suffered a miscarriage in the second trimester (live birth rate, 75%).

CONCLUSION

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS is a feasible and effective for treatment of DUL because it preserves the uterus and yields favorable reproductive outcomes. The cold surgery and fenestration method minimizes electrical and thermal damage to the endometrium surrounding the myoma, consequently reducing surgical risks.

Clinico-hysteroscopic analysis of severe intrauterine adhesions among Nigerian infertile women

Introduction

Severe intrauterine adhesions are difficult to manage and are associated with poor reproductive outcomes following treatment. The objective was to study the clinical presentation and hysteroscopic findings of severe intrauterine adhesions seen at hysteroscopy in two fertility/gynaecological endoscopy units in Nigeria.

Methods

A prospective study of 19 out of 76 women managed for intrauterine adhesions in our units. Data were analyzed with STATA software, version 12.0 SE (Stata Corporation, TX, USA).

Results

Severe intrauterine adhesion accounted for 19 (25.0%) of 76 cases of intrauterine adhesions managed during the period. This constituted 11.9% of 160 infertile women who had diagnostic hysteroscopies in our units over the study period. The mean duration of symptom was 4.2 years +/-3.2. Amenorrhea in association with infertility (68.4%) was the main presenting complaint. Secondary dysmenorrhea and cyclical abdominal pain were found in 10.8% and 31.6% of the women respectively. The main aetiological events were complicated caesarean section (42.1%) and abdominal myomectomy (26.3%). The adhesions were mainly dense (52.6%) and multiple (94.7%) with complete involvement of the uterine cavity in all the cases. Obliterative lesions were seen in 63.2% of the women.

Conclusion

The main clinical presentation of severe IUA was amenorrhea and infertility while the major risk factors were complicated caesarean section and myomectomy. The adhesions were mainly multiple, dense, obliterative and complete.

Effect of myomectomy on endometrial cavity: A prospective study of 51 cases

CONTEXT

Fibroids are the most common tumors of the uterine cavity. Most of them are diagnosed during the reproductive age when the fertility is an important concern for the female. However, complications can occur after removal of fibroid (myomectomy) too for future pregnancy. Though myomectomy has been sighted as a cause of intrauterine adhesions data regarding the effect of myomectomy on endometrial cavity is lacking.

AIMS

Evaluate the incidence of intrauterine adhesion formation after myomectomy and to identify the associated factors.

MATERIALS AND METHODS

In this prospective observational study, hysteroscopy was done in 51 infertile patients who had undergone myomectomy 3 months before in a tertiary care center from 2012 to 2015. The presence of intrauterine adhesions noted on hysteroscopy was investigated on the basis of size, number, location and type of fibroid removed, along with intraoperative breach of the uterine cavity.

STATISTICAL ANALYSIS

Chi-square test was used for the calculating significant difference in frequency of discrete variables in two groups. P < 0.05 was considered significant.

RESULTS

Intrauterine adhesions were seen in 11 out of 51 (21.57%) cases. No significant relationship between intrauterine adhesions and type, size or number of fibroid was observed. No statistical difference in the rate of adhesion formation was seen irrespective of breach of the uterine cavity during myomectomy.

CONCLUSION

Intrauterine adhesion formation after myomectomy is not related to the type of surgery or the nature of fibroid. However, in all cases desiring fertility postoperative hysteroscopy is highly recommended to diagnose and treat these adhesions early.

Mitochondrial DNA Haplogroup R Confers a Genetic Risk Factor for Intrauterine Adhesion in Han Women Population

BACKGROUND

To determine whether a specific mitochondrial DNA (mtDNA) haplogroup is implicated in the pathogenesis of intrauterine adhesion (IUA).

METHODS

Peripheral blood samples were collected from 486 women with (case group, n = 154) and without IUA (control group, n = 332) at the Women's Hospital, Zhejiang University School of Medicine. Genomic DNA was extracted from the blood, and the mtDNA haplogroups of Han women M, N and R were determined by sequencing hypervariable mtDNA segments and testing diagnostic polymorphisms in the mtDNA coding region.

RESULTS

Women with mtDNA haplogroup R had an independently increased genetic risk factor for IUA with an OR 1.77 (95% CI 1.16-2.70, p = 0.009) compared with women without. Moreover, repeated intrauterine surgery within 1 month and number of intrauterine operations were both significantly associated with IUA (p < 0.001).

CONCLUSIONS

These results suggest that mtDNA haplogroup R, one of the main mtDNA haplogroups in Han population, is a strong independent genetic risk factor for women with IUA.

Intrauterine synechiae after myomectomy; laparotomy versus laparoscopy: Non-randomized interventional trial

BACKGROUND

Leiomyomata is the most frequent gynecological neoplasm. One of the major complications of myomectomy is intrauterine adhesion (synechiae).

OBJECTIVE

To evaluate and compare the rate and severity of synechiae formation after myomectomy by laparotomy and laparoscopy.

MATERIALS AND METHODS

In this non-randomized interventional trial, hysteroscopy was performed in all married fertile women who had undergone myomectomy (type 3-6 interamural and subserosal fibroids) via laparotomy and laparoscopy in Tehran's Arash Hospital from 2010 to 2013. Three months after the operation, the occurrence rate and severity of intrauterine synechiae, and its relationship with type, number and location of myomas were investigated and compared in both groups.

RESULTS

Forty patients (19 laparoscopy and 21 laparotomy cases) were studied. Both groups were similar regarding the size, type (subserosal or intramural), number and location of myoma. The occurrence rate of synechiae in the laparoscopy and laparotomy group was 21% and 19%, respectively; showing no significant difference (p=0.99). Among all patients, no significant relationship was found between the endometrial opening (p=0.92), location (p=0.14) and type of myoma (p=0.08) with the occurrence rate of synechiae. However, a significant relationship was observed between myoma's size (p=0.01) and the location of the largest myoma with the occurrence of synechiae (p=0.02).

CONCLUSION

With favorable suturing methods, the outcome of intrauterine synechiae formation after myomectomy, either performed by laparotomy or laparoscopy, is similar. In all cases of myomectomy in reproductive-aged women, postoperative hysteroscopy is highly recommended to better screen intrauterine synechiae.

Regeneration of uterine horns in rats using collagen scaffolds loaded with human embryonic stem cell-derived endometrium-like cells

A variety of diseases may lead to hysterectomies or uterine injuries, which may form a scar and lead to infertility. Due to the limitation of native materials, there are a few effective methods to treat such damages. Tissue engineering combines cell and molecular biology with materials and mechanical engineering to replace or repair damaged organs and tissues. The use of human embryonic stem cells (hESCs) as a donor cell source for the replacement therapy will require the development of simple and reliable cell differentiation protocols. This study aimed at efficiently generating endometrium-like cells from the hESCs and at using these cells with collagen scaffold to repair uterine damage. The hESCs were induced by co-culturing with endometrial stromal cells, and simultaneously added cytokines: epidermal growth factor (EGF), platelet-derived growth factor-b (PDGF-b), and E2. Expression of cell specific markers was analyzed by immunofluorescence and reverse trascription-polymerase chain reaction to monitor the progression toward an endometrium-like cell fate. After differentiation, the majority of cells (>80%) were positive for cytokeratin-7, and the expression of key transcription factors related to endometrial development, such as Wnt4, Wnt7a, Wnt5a, Hoxa11, and factors associated with endometrial epithelial cell function: Hoxa10, Intergrinβ3, LIF, ER, and PR were also detected. Then, we established the uterine full-thickness-injury rat models to test cell function in vivo. hESC-derived cells were dropped onto collagen scaffolds and transplanted into the animal model. Twelve weeks after transplantation, we discovered that the hESC-derived cells could survive and recover the structure and function of uterine horns in a rat model of severe uterine damage. The experimental system presented here provides a reliable protocol to produce endometrium-like cells from hESCs. Our results encourage the use of hESCs in cell-replacement therapy for severe uterine damage in future.

Intrauterine adhesions after open myomectomy: an audit

OBJECTIVE

To estimate the incidence of intrauterine adhesions after open myomectomy.

STUDY DESIGN

A prospective audit descriptive study was conducted involving thirty-six women who had undergone open myomectomy for symptomatic fibroids at a large undergraduate teaching hospital. A follow-up out-patient hysteroscopy was performed three months after surgery.

RESULTS

At hysteroscopy, eighteen patients (50%) were found to have mild to moderate intrauterine adhesions. The number of fibroids removed was significantly higher in patient who developed adhesions (median value 22 versus 9.5, p<0.05). Pre-operative GnRHa therapy, uterine size, opening of the uterine cavity during surgery, specimen weight, estimated blood loss, post-operative bleeding or pyrexia were similar whether or not adhesions were found.

CONCLUSION

Open myomectomy represents an important but currently underappreciated aetiological factor in the formation of intrauterine adhesions.

Uterine fibroids: current perspectives

Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman's menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.