Hysteroscopy in 2001: a comprehensive review

Transcription

1 Acta Obstet Gynecol Scand 2001; 80: Copyright C Acta Obstet Gynecol Scand 2001 Printed in Denmark All rights reserved Acta Obstetricia et Gynecologica Scandinavica ISSN REVIEW Hysteroscopy in 2001: a comprehensive review FRITZ WIESER 1, CLEMENS TEMPFER 2, CHRISTINE KURZ 1 AND FRITZ NAGELE 1 From the 1 Division of Gynecological Endocrinology & Reproductive Medicine, and the 2 Division of Gynecology and Obstetrics, University Department of Obstetrics and Gynecology, Vienna, Austria Acta Obstet Gynecol Scand 2001; 80; C Acta Obstet Gynecol Scand 2001 Key words: diagnostic hysteroscopy; endometrial ablation; hysteroscopic metroplasty; hysteroscopic myomectomy; outpatient hysteroscopy Submitted 2 March, 2001 Accepted 18 April, 2001 Bozzini, in 1807, was the first person to use a mechanical light conductor for inspection of the uterine cavity (1). Thus, hysteroscopy is apparently the oldest endoscopic procedure described in medical literature. In today s field of obstetrics and gynecology, hysteroscopy has become a cornerstone in evaluating and treating infertile women and those with functional or anatomical uterine anomalies. Minimally invasive surgery has experienced a boom over the last 20 years, resulting in a wide expansion of techniques and indications for diagnostic as well as operative hysteroscopy. In the field of diagnostic hysteroscopy, numerous innovations have entered the clinical routine, among them small-diameter rigid and flexible hysteroscopes. The field of hysteroscopic surgery has profited considerably from the rapid development of electrosurgical devices and laser technology. Today, diagnostic hysteroscopy allows for an easy, precise, and cost-effective evaluation of the uterine cavity and subsequent detection of intrauterine pathology. Hysteroscopic surgery offers a wide range of intrauterine surgical procedures such as myomectomy, polypectomy, metroplasty, and endometrial ablation. Abbreviations: GnRH: gonadotropin releasing hormone; ND-YAG: neodymium: yttrium-aluminum garnet; TRCE: transcervical resection of the endometrium; HELA: human endometrial lasor ablation; D&C: dilatation and curettage. Diagnostic hysteroscopy Diagnostic hysteroscopy has now replaced conventional cervical dilatation and curettage (D&C) for the evaluation of the uterine cavity in industrialized countries. Numerous studies (Table I [1 16], Table II [17 34]) have confirmed the efficacy of diagnostic hysteroscopy, the single most common indication being abnormal uterine bleeding (12). Almost 30% and 75% of gynecological consultations of premenopausal and postmenopausal women, respectively, are related to abnormal uterine bleeding (6). Other indications for diagnostic hysteroscopy comprise fertility work-up, suspicious ultrasound of the uterus, and dysmenorrhea. Direct visualization of the uterine cavity will detect intrauterine pathologies in up to 50% of women with abnormal vaginal bleedings (12). Diagnostic hysteroscopy is a reliable tool for the detection of uterine fibroids, endometrial polyps, congenital uterine malformations, synechiae, and complete Asherman s syndrome and provides precise diagnosis of other lesions, previously detected by ultrasound. In contrast, endometrial biopsy is a blind office procedure with a reportedly low sensitivity and will miss small lesions in up to 50% of cases (35). Recent studies confirm the diagnostic accuracy and the high degree of feasibility of diagnostic hysteroscopy carried out as an outpatient procedure (10, 12, 15, 24, 28, 30). In order to facilitate outpatient hysteroscopy and to increase the success

2 774 F. Wieser et al. Table I. Descriptive studies on diagnostic hysteroscopy Author (year) Patient nos. Technique Distention Analgesia (GA, LA) Successrate Valle et al. (1975) (2) 110 Rigid hysteroscopy Dextran LA (PCB); GA 100% Sciarra & Valle (1977) (3) 320 Rigid hysteroscopy Dextran LA (PCB); GA 100% Taylor & Cumming (1979) (4) 100 Rigid hysteroscopy Dextran GA 96% Barbot et al. (1980) (5) 1000 Rigid hysteroscopy CO 2 None; LA (PCB), if indicated; GA 98% Mencaglia et al. (1987) (6) 618 Rigid hysteroscopy nd None n.d. Seinera et al. (1988) (7) 332 Rigid hysteroscopy CO 2 LA (nd), GA 100% De Jong et al. (1990) (8) 160 Rigid hysteroscopy CO 2 LA (PCB) 95% Downes & al-azzawi (1993) (9) 100 Rigid hysteroscopy CO 2 LA (ICB) 100% Downes & al-azzawi (1993) (10) 259 Rigid hysteroscopy CO 2 LA (ICB) 98.1% Nagele et al. (1995) (11) 120 Rigid hysteroscopy N/saline LA (PCB), if indicated 85.8% Nagele et al. (1996) (12) 2500 Rigid hysteroscopy N/saline, CO 2 LA (ICB), if indicated 96.4% Towbin et al. (1996) (13) 149 Rigid hysteroscopy CO 2 LA (PCB) 100% Kremer et al. (1998) (14) 554 Flexible hysteroscopy CO 2 None 90.5% Wieser et al. (1999) (15) 360 Rigid hysteroscopy N/Saline LA (ICB); Spray 94.2% Ceci et al. (2000) (16) 88 Rigid hysteroscopy N/Saline None 100% GAΩgeneral anesthesia; ICBΩintracervical block; LAΩlocal anesthesia; n.d.ωno data; PCBΩparacervical block. Table II. Comparative studies on diagnostic hysteroscopy Patient Type Author (year) Nos of trial Comparison Technique Analgesia Success rate Hald et al. (1988) (17) 15 vs. 15 RCT Prostaglandins vs. placebo Rigid hysteroscopy PCB 100 vs. 100% Broadbent et al. (1992) (18) 50 vs. 50 RCT ICB vs. placebo Rigid hysteroscopy ICB vs. placebo 96% vs. 98% Vercellini et al. (1994) (19) 89 vs. 92 RCT PCB vs. none Rigid hysteroscopy PCB vs. none 97.7% vs. 97.8% Akkad et al. (1995) (20) 414 CCS AUB on HRT vs. AUB vs. PMB Rigid hysteroscopy ICB 100% Zupi et al. (1995) (21) 23 vs. 22 RCT Spray anesthesia vs. placebo Rigid hysteroscopy ICB vs. placebo 100% vs. 100% Nagele et al. (1996) (22) 157 vs. 153 CCS AUB vs. PMB Rigid hysteroscopy ICB, if indicated 96.8% vs. 92.2% Nagele et al. (1996) (23) 79 vs. 78 RCT CO 2 vs. N/saline Rigid hysteroscopy ICB, if indicated 100% vs. 100% Cicinelli et al. (1997) (24) 40 vs. 40 RCT Anesthetic spray vs. placebo Rigid hysteroscopy Spray vs. placebo 100% vs. 100% Nagele et al. (1997) (25) 49 vs. 46 RCT Analgesics vs. placebo Rigid hysteroscopy ICB, if indicated 95.9% vs. 95.7% Davies (1997) (26) 60 vs. 60 RCT Spray anesthesia vs. placebo Rigid hysteroscopy Spray vs. placebo 91.7 vs. 96.7% Wieser et al. (1998) (27) 150 vs.150 CCS Spray anesthesia vs. none Rigid hysteroscopy ICB, if indicated 98.7% vs. 93.3% Tahir et al. (1999) (28) 200 vs. 200 RCT Outpatient vs. day case Rigid hysteroscopy PCB or ICB vs. GA 97.0% vs. 100% Preutthipan & Herabutya 46 vs. 45 RCT Prostaglandins vs. placebo Rigid hysteroscopy GA 100% vs. 100% (1999) (29) Kremer et al. (2000) (30) 50 vs. 50 RCT Outpatient vs. day-case 3.6 m, 5 mm flexible ICB, if indicated 96% vs. 100% hysteroscope vs. GA Soriano et al. (2000) (31) 62 vs. 56 RCT Spray anesthesia vs. placebo Flexible hysteroscopy Lidocaine 100% vs. 100% vs. placebo Wong et al. (2000) (32) 250 vs. 250 RCT Anesthetic gel vs. placebo Rigid hysteroscopy Lignocaine gel 99.2% vs. 99.6% vs. placebo Giorda et al. (2000) (33) 119 vs. 121 RCT 5 mm vs. 5 mm hysteroscope Rigid hysteroscopy None vs. PCB 74% vs. 84% with PCB vs. 3.5 mm vs. none vs. 99.6% hysteroscope Unfried et al. (2001) (34) 72 vs. 70 RCT Rigid vs. flexible hysteroscope Rigid/flexible Spray anesthesia; 100% vs. 100% hysteroscopy ICB if indicated AUBΩabnormal uterine bleeding; CCSΩcase-control study; GAΩgeneral anesthesia; ICBΩintracervical block; PCBΩparacervical block; PMBΩfrank postmenopausal bleeding; RCTΩrandomized controlled trial. rate of the procedure, spray anesthesia has been introduced (21, 24, 26, 27). It has been demonstrated that lidocaine spray treatment of the cervix significantly decreases the need for injectable local anesthetics and improves the tolerability of hysteroscopy, resulting in procedure-specific success-rates of almost 100%. An alternative approach uses preoperative local application of prostaglandins in an attempt to soften the cervix (17, 29). However, side effects such as abdominal cramps and blurred hysteroscopic vision due to a distended cervical canal have precluded the widespread use of this technique. Of note, the use of preoperative oral analgesics has been shown not to effectively reduce lower abdominal pain during hysteroscopy (25). Distension of the uterus is necessary for visual inspection of the uterine cavity. This may be

3 Diagnostic and operative hysteroscopy 775 achieved by local instillation of electrolyte solutions, electrolyte-free solutions, or CO 2 gas (23, 36). Flow rates of ml/min and a pressure 100 mmhg are recommended for the use of CO 2 gas as distension medium (37). Recommendations for uterine distension with normal saline cite optimal pressure rates of 120 to 150 mmhg (37). Although CO 2 gas is generally well tolerated, uterine distension with saline has been shown to be more comfortable for the patient, to be more cost-effective and to provide superior hysteroscopic view in case of intrauterine bleeding (23). Diagnostic hysteroscopy has a very low complication rate of 0.13%, including laceration of the cervix by a tenaculum, fluid overload and uterine perforation (37, 38). Two types of instruments are available, i.e. rigid and flexible hysteroscopes. Outer sheaths are available with an operating channel, through which it is possible to perform minor surgery, such as removal of IUDs, directed biopsies or polypectomies under hysteroscopic view (39 41). In office settings, most clinicians use rigid hysteroscopes with a diameter between 1.7 and 5 mm (39). Major advantages of rigid as compared to flexible hysteroscopes include a higher optical quality, a shorter mean operative time, and lower instrument costs. On the other hand, flexible instruments, originally designed for gastrointestinal investigations, reduce patient discomfort during the procedure due to the unique properties of flexible endoscopes (14, 34, 42, 43). In summary, diagnostic hysteroscopy is a simple and safe procedure permitting direct visualization of the uterine cavity on an outpatient basis. The success-rate of this procedure reaches almost 100%. Displaying the hysteroscopic image simultaneously to the physician and the patient helps to explain the diagnosis to the patient, presumably increasing satisfaction and compliance to subsequent treatment (13). Diagnostic hysteroscopy has become the gold standard for the evaluation of the uterine cavity. Hysteroscopic surgery Technical innovations of hysteroscopic instruments and equipment together with the desire of women to preserve their uterus despite a given dysfunction has led to a sharp rise in operative hysteroscopy over the last 10 years. The electrosurgical resectoscope has been used by urologists for half a century and has been adapted to allow for the instrument to be atraumatically introduced into the uterus (44). Another energy-source used with hysteroscopic instruments are fiberoptic lasers with the Nd-YAG laser being the most commonly used tool. Nd-YAG lasers offer a capacity of deep co- agulation up to 5 mm. The most frequently performed hysteroscopic procedures with fiberoptic lasers and electrosurgical instruments are endometrial ablation, metroplasty, myomectomy, and polypectomy. Endometrial ablation Menorrhagia accounts for approximately 35% of gynecologic consultations and 60% of these women traditionally undergo hysterectomy (45). Endometrial ablation (Table III [46 60]) is an alternative intervention modality for these women, obviating the need to remove the uterus (61). The principle of this ablative technique is to remove and/or destroy the whole thickness of the endometrium as well as the superficial myometrium to ensure complete removal of endometrium and basal glands. Ablation can be induced by Nd-YAG laser coagulation (HELA) or electrocautery using the hysteroscopic resectoscope (TRCE) (62, 63). The aim of all these procedures is to induce a therapeutic Asherman s syndrome, thus stopping or significantly decreasing the menstrual flow while avoiding the need for hysterectomy. The Nd-YAG laser has advantages compared with electrosurgical instruments. Nd-YAG lasers penetrate the endometrium to a depth of 5 mm, offer good coagulation activity, and pass through clear fluids with a low risk of perforation (37, 38). Ringer lactate is currently used as distension medium and provides clear vision in combination with Nd-YAG laser procedures (37). The success rate of laser ablation, defined as significant reduction/inhibition of menstrual flow, is reported to be 80% to 95%. Laser ablation is associated with a very low risk of perforation during insertion with the hysteroscope (0.3%), infection (0.4%), and perioperative bleeding ( 0.1%) (47). The most common serious complication of laser ablation is excessive intravasation of the distension medium into the systemic circulation with subsequent fluid overload and pulmonary edema in about 0.4% of cases (51, 64, 65). Laser ablation, however, is the more costly procedure compared to electrosurgical ablation (66). Electrosurgical ablation with the cutting loop or the roller ball uses electricity and must thus be performed in electrolyte-free distention media, e.g. glycine 1.5%, sorbitol 3%, or mannitol 5% (37). Most surgeons prefer a cutting loop of 24 Fr in diameter, which removes 4 mm of tissue with one pass (67, 68). Uterine perforation with electrocautery can be expected in 0% to 2% of cases (48). In order to avoid perforation at the corneal regions of the uterus, preferential use of a small-diameter roller ball (2 mm) in this area has been proposed (67). The largest

4 776 F. Wieser et al. Table III. Descriptive studies on endometrial ablation Patient Mean Author (year) nos. Technique Follow-up Pretreatment S A C HE Repeat ablation Bent & Ostergard (1990) (46) 45 HELA 2 a Yes 81% 33% 6.6% 13.3% 0% Garry et al. (1991) (47) 859 HELA 6 mo Yes 97% 60% 1.2% 2.9% 2.7% Magos et al. (1991) (48) 250 TRCE 2.5 a Yes 80% 27 42% 4.8% 4.0% 6.5% Daniel et al. (1992) (49) 61 RB 6 30 mo Yes 80.3% 29.5% 1.6% 6.6% 4.8% Erian & Goh (1996) (50) 126 TRCE 13 mo Yes n.d. 44.7% 4.0% 6.3% 4.9% Garry et al. (1995) (51) 524 HELA 15 mo Yes 83.4% 28.9% 0.3% 6.8% 14.3% Vilos et al. (1996) (52) 800 RB 2.5,TRCE 9,10 12 mo Yes n.d. 60% 3.9% 2.1% 4% Istre 1996 (53) 412 TRCE 5 a No 91% 60% 18% 6.1% 9.0% O Connor & Magos (1996) (54) 525 TRCE 5 a Yes 79% 50% 6% 8.8.% 9.1% Phillips et al. (1998) (55) 873 HELA 6.5 a Yes 89.3% 37.6% 0.2% 21% 14.6% Hawe et al. (1999 (56) 50 Balloon 14 mo Yes 96% 68% 0% 2% 2% Das Dores et al. (1999) (57) 26 Hydro Therm Ablator 18 mo Yes 96.2% 47% 0% 3.9% 7.7% Teirney et al. (2000) (58) 39 RB 5.4 a Yes n.d. 46% 0% 5.1% 0% Weisberg et al. (2000) (59) 20 Hydro Therm Ablator 12 mo Yes n.d. 55.6% 0% 5% 0% Donnez et al. (2000) (60) 100 ELLITT 12 mo Yes 98% 71% 0% 3% 0% AΩamenorrhea; CΩcomplication; ELLITΩendometrial laser intrauterine thermal therapy; HEΩhysterectomy; HELAΩhuman endometrial laser ablation; MEAΩ microwave ablation; n.d.ωno data; RBΩrollerball ablation; SΩsatisfaction; TRCEΩtranscervical resection of the endometrium; MoΩmonths, aωyears. study looking at complications associated with the three most widely used ablation techniques revealed an overall complication rate between 2.1% and 6.4% (69). Of note, laser or roller-ball ablation is significantly safer than loop resection with the incidence of uterine perforation being strongly linked to operator s experience (68). Of the described methods, only TRCE produces tissue for histologic examination, since HELA and roller ball coagulation completely destroy the endometrium. Endometrial preparation prior to electrosurgery is helpful in reducing operation time and lowering the complication rate. For this purpose, drugs such as danazol and gonadotropin releasing hormone (GnRH) agonists have been used (70 72). Preoperative endometrial thinning has been shown to reduce fluid absorption, operating time, and blood loss and to improve intraoperative vision (70). Whether endometrial thinning prior to surgery also results in higher long-term success rates has not been convincingly demonstrated. Several randomized trials compared endometrial ablation with abdominal hysterectomy in women with menorrhagia (Table IV [73 87]). Each of these trials reported endometrial ablation to be associated with a shorter operating time, fewer complications, and a shorter time of return to work compared to hysterectomy. Furthermore, endometrial ablation resulted in significant savings of direct treatment related costs (73, 75, 88). In two studies, endometrial ablation was also compared with vaginal hysterectomy. The Medical Research Council trial (89) concluded that endometrial ablation had less post-operative morbidity; Vilos et al. found endometrial ablation effective in 82% of women, and 58% less expensive than vaginal hysterectomy (52). An increasing number of surgeons reported endometrial ablation as a useful tool in treating women with abnormal/excessive uterine bleeding under hormone replacement therapy (90, 91). Most authors agree that endometrial ablation does not effectively treat dysmenorrhea (92). In conclusion, the three most important advantages of endometrial ablation can be summarized as avoidance of major surgery, fast return to normal functioning, and short hospitalization (61). There are several reports on cases of endometrial carcinoma (93 96) and intrauterine pregnancies (97, 98) following endometrial ablation. Such findings clearly show that endometrial ablation is a macroscopic procedure, which does not remove the entire endometrium. This underlines the need for careful patient counseling and a comprehensive diagnostic work-up prior to surgery. Clearly, simultaneous tubal sterilization should be discussed and women with a high risk for endometrial carcinoma should be offered hysterectomy rather than endometrial ablation. At present, much effort is spent on the development and promotion of numerous alternative and presumably less invasive techniques of endometrial ablation, the idea being to reduce both the amount of surgical skills required and complications associated with established methods. These modalities are microwave energy ablation, photodynamic therapy, cryoablation, hot saline therapy, intrauterine laser therapy (ELLIT), intrauterine bipolar mesh (Novacept), and balloon systems (50, 60, 83 87, ). Briefly, almost all of these techniques are non-hys-

5 Diagnostic and operative hysteroscopy 777 Table IV. Comparative studies on endometrial ablation Patient Operating Further Author (year) nos. Type Comparison time (min) Satisfaction Complication surgery Hospital charges Sculpher et al. (1993) (73) 99 vs. 97 RCT TRCE vs. HE 51.2 vs min 84% vs. 95% 6.1 vs. 5.2% 12 vs. 0% ; more for hysterectomy Dwyer et al. (1993) (74) 97 vs. 99 RCT TRCE vs. HE 35 vs. 45 min 85% vs. 94% 4.1% vs. 3.3% 11.3% vs. 2% n.d. Brooks et al. (1994) (75) 85 vs. 255 CCS TRCE vs. HE 15.3 vs $ vs $ Pinion et al. (1994) (76) 105 vs. 99 RCT TRCE/HELA vs vs % vs. 89% 21% vs. 15 % 26.6% vs. n.d. HE Alexander et al. (1996) (77) 99 vs. 105 RCT HE vs. n.d. TRCE/HELA Bhattacharya et al. 188 vs. 184 RCT TRCE vs. HELA 21 vs. 30 min 91% vs. 90% 7.2% vs. 11.9% 20% vs. 16% 145 more (1997) (66) for HELA Cooper et al. (1997) (78) 93 vs. 94 RCT TRCE vs. Medical 76% vs. 27% 0% vs. 0% 2.1% vs. 1.1% n.d. treatment Crosignani et al. (1997) (79) 35 vs. 35 RCT TRCE/RB vs. IUD 94% vs. 85% 0% vs. 0% 2.9% vs. 2.9% n.d. Hidlebaugh & Orr (1998) (80) 64 vs. 46 RCT TRCE vs. HE 38 vs % for TCRE 6.3 vs. 21.7% 12.5% vs $ vs $ Meyer et al. (1998) (81) 128 vs. 137 RCT Balloon vs. Less for balloon 86% vs. 87% 0% vs. 3.2% 1.7% vs. 2.2% n.d. RB p 0.05 Grant EATG (1999) (82) 105 vs. 99 RCT TRCE/HELA vs. 80% vs. 89% 38% vs. 1% 1231 vs. HE 1332 Vercellini et al. (1999) (83) 44 vs. 47 RCT TRCE vs. VapE 9.2 vs min 93% vs. 96% 0% vs. 0% 2.3 vs. 0% n.d. Gervaise et al. (1999) (84) 74 vs. 73 RCT TRCE vs. Balloon 44.8 vs min 76% vs. 83% 0% vs. 0% 8.1% vs. 9.6% n.d. Cooper et al. (1999) (85) 134 vs. 129 RCT TRCE vs. MEA 15 vs min 90% vs. 94% 11% vs. 14% 10.6% vs. 9.7% n.d. Grainger et al. (2000) (86) 131 vs. 124 RCT Balloon vs. RB n.d vs % vs. 0% 3.1% vs. 8.9% n.d. Corson et al. (2000) (87) 123 vs. 132 RCT TRCE-RB vs vs. 83.0% vs. 3.3% vs. 8.3% vs. n.d. Balloon 23.1 min 86.9% 1.4% 3.7% CCSΩcase-control study; HEΩhysterectomy; MEAΩmicrowave endometrial ablation; n.d.ωno data; RBΩrollerball; RCTΩrandomized controlled trial; TRCEΩ transcervical resection of the endometrium; VapEΩvaporizing electrode. teroscopic, blind procedures using disposable and expensive probes. Many systems are promoted by highly regarded names in the field of gynecologic endoscopy, but long-term efficacy data are lacking. To conclude with Kremer & Duffy:... none of these methods fulfill all the criteria of a simple, safe technique that works and that can be performed in an outpatient setting (108). In summary, hysteroscopic endometrial ablation is one of the most carefully and extensively evaluated minimally invasive surgical procedures in the field of gynecology. A new and revolutionary method at the time of introduction, hysteroscopic endometrial ablation has now passed all phases of research and became an evidence-based alternative to hysterectomy. Because it is no definitive treatment, success is determined by long-term outcome. On average, satisfaction-rates are 80% and almost 90% of women are able to avoid hysterectomy (Fig. 1) (51, 52, 54, 55, ). Of note, at this time HELA, TRCE and roller ball ablation are the Fig. 1. Long-term follow-up studies on endometrial ablation. HEΩhysterectomy.

6 778 F. Wieser et al. only ablative techniques which can be recommended as gold standard. Hysteroscopic myomectomy and polypectomy Uterine fibroids and endometrial polyps are the most common benign tumors of the uterus and are often the cause of abnormal uterine bleeding. Longterm complications are infertility and chronic pain (116, 117). The resectoscope as a means to treat intrauterine fibroids has been originally introduced by Neuwirth & Amin (118). Endoscopic resection of fibroids in women with abnormal uterine bleeding (44) has been reported to be feasible and safe by many authors (Table V [ ]). Despite some limitations of endoscopic surgery, there has been a world-wide increase of endoscopic myomectomies and polypectomies ( ). Hysteroscopic resection can be considered a standard procedure for fibroids entirely or mostly within the uterine cavity (119, 120, 136, 137). When a large portion of the fibroid is positioned intramurally, it is feasible to resect the accessible portion of the fibroid until the resection area is flush with the remaining part of the uterus. Success rates of hysteroscopic myomectomy, defined as absence of menorrhagia, have been reported in about 80% of women (117, 125, 129). Recurrence of fibroids after hysteroscopic surgery is observed in about 25% of cases, a figure comparable to laparoscopic myomectomy for subserous and intramural tumors (138). Another indication for hysteroscopic myomectomy is subfertility/infertility. The desire to postpone reproduction and to conceive at an advanced age has led to an increased frequency of hysteroscopic fibroid and endometrial polyp resection (135, 139, 140). Fibroids interfere with conception and may lead to miscarriage, pregnancy complications, and poor outcome of in-vitro fertilization (IVF) ( ). Cumulative conception rates between 43% and 63% have been reported after hysteroscopic myomectomy (117, 128, 144, 145). In comparison with laparoscopic myomectomy, the advantages of hysteroscopic myomectomy include shorter hospitalization, reduced need for postoperative care, shorter recovery period, reduction of treatment-related costs, and earlier resumption of normal activities (133). Endometrial polyps are detected in 20% of women with abnormal bleedings and in 15% of infertile women (12). The final surgical management of patients with endometrial polyps is usually decided on the basis of hysteroscopic findings, including the location, size, and thickness of the pedicle (128, 132). Endometrial polyps can be removed with scissors, laser beam, or a resectoscope under hysteroscopic control. In conclusion, hysteroscopic surgery for fibroids and endometrial polyps is a well-established, costeffective and safe technique, allowing women to preserve their uterus and/or regain regular cycles and fertility. Hysteroscopic metroplasty The septate uterus represents the most common intrauterine congenital malformation associated with a high incidence of reproductive failure and obstetric complications (146). The transcervical route to treat the septate uterus has initially been proposed in 1884 by Ruge (147), but the septate uterus has traditionally been treated with abdominal metroplasty by way of a wedge resection (Wedge pro- Table V. Studies on hysteroscopic myomectomy/polypectomy Author (year) Patient no Technique M / P Mean op time C Cure Follow-up Further surgery HE Neuwirth & Amin (1976) (118) 5 R M n.d. No 100% 20% Hallez et al. (1987) (119) 61 R M 15 min 1.6% 98.3% 1 3 mo 1.6% 0 Loffer (1990) (120) 53 R M/P n.d. 5.6% 93% 1 a 24.5% 9.4% Donnez et al. (1990) (121) 60 HELA M 24 min 0% 100% 8 mo 20% 0% Derman et al. (1991) (122) 108 R M n.d. 5.5% 83.9% 9 a 15.8% 6.5% Hucke et al. (1992) (123) 39 R M 32 min 2.6% 100% 10.8 mo 2.6% Indman (1993) (124) 51 R M n.d. 3.9% 94% 2.2 a 9.8% 5.9% Wamsteker et al. (1993) (125) 51 R M n.d. 2.0% 94.1% 20 mo 29.4% 5.9% Goldenberg et al. (1995) (126) 15 R M 25.5 min 0% 12 mo Hallez (1995) (127) 274 R M n.d. 0.4% 67.6% Ø7a 50 mo 15.7% 2.2% Nagele et al. (1996) (128) 50 R, scissors P/M n.d. 0% 77.6% 21 mo 6% 4% Cravello et al. (1996) (129) 102 R M/P 27.1 min 2.0% 86.3% 3.1 a 10.7% 5.9% Hart et al. (1999) (130) 122 R M 28.1 min 4.9% 86.0% 2.3 a 16.0% 4.9% Emanuel et al. (1999) (131) 285 R M n.d. 1.1% 46 mo 14.5% 7.0% Varasteh et al. (1999) (116) 78 R M/P n.d. n.d. n.d. 12 mo Vercellini et al. (1999) (117) 108 R M 24 min 0.9% 81.5% 41 mo 10.1% 6.5% aωyears; CΩcomplication; HEΩhysterectomy; HELAΩhuman endometrium laser ablation; moωmonths; n.d.ωnot determined; MΩhysteroscopic myomectomy; PΩhysteroscopic polypectomy; RΩresectoscope.

7 Diagnostic and operative hysteroscopy 779 Table VI. Outcome of hysteroscopic metroplasty Outcome Author Patient nos. Technique Total pregnancy rate Life-birth rate Edstrom (1974) (149) 2 Biopsy forceps 1 0 Chervenak & Neuwirth (1981) (150) 2 Microscissors 1 1 Rosenberg et al. (1981) (151) 1 Microscissors Perino et al. (1985) (152) 11 Microscissors n.d. n.d. DeCherney et al. (1986) (153) 72 Resectoscope Corson & Batzer (1986) (154) 18 Resectoscope, rigid scissors Fayez (1986) (155) 19 Microscissors Perino et al. (1987) (156) 24 Resectoscope March & Israel (1987) (157) 91 Microscissors Valle & Sciarra (1986) (158) 59 Flexible microscissors Candiani et al. (1991) (159) 21 Laser, microscissors Choe & Baggish (1992) (160) 19 Laser Fedele et al. (1993) (161) 102 Laser, scissors Cararach et al. (1994) (162) 81 Scissors/Resectoscope Valle (1996) (163) 124 Microscissors, Resectoscope Grimbizis et al. (1998) (164) 57 Resectoscope cedure), incision of the septum (Tompkins procedure) or transverse incision (Strassmann procedure) (148). Fetal survival after abdominal metroplasty was observed to be between 73% and 91%. The first hysteroscopic resection of a uterine septum was performed by Edstrom in 1974 and has subsequently replaced abdominal metroplasty (Table VI [ ]). Hysteroscopic metroplasty is superior to the abdominal procedure and is today widely accepted as the treatment of choice in cases of a septate uterus (148, 165). Hysteroscopic resection of a uterine septum can be performed by bipolar coagulation and subsequent division with endoscissors (159, 166), Nd-Yag laser (159, 160) or resectoscope (153, 154). Regarding postoperative intrauterine morphology and pregnancy outcome, all three methods of septum resection are equal with crude pregnancy rates between 29% and 71% (165). Hysteroscopic removal of the septum is an effective procedure. There remains, however, a very low risk of perforation (38). Therefore, hysteroscopic septum removal should be performed under laparoscopic or ultrasound control (167). When a residual septum larger than 1 cm in diameter is found in the follow-up hysteroscopy, generally recommended to be performed 4 to 6 weeks after the procedure, a second operation is required (168). Compared with traditional methods, hysteroscopic metroplasty offers shorter operating and hospitalization times and presumably improves the subsequent obstetric career. In conclusion, hysteroscopic metroplasty through the vaginal route using laser technology, electrocautery or scissors, is the best available surgical option for the woman with a septate uterus, although evidence is not based on prospective, randomized trials. Conclusion Diagnostic hysteroscopy can be regarded as the gold standard for the evaluation of the uterine cavity. Hysteroscopic surgery is a modern, safe, and cost-effective diagnostic and therapeutic tool for the investigation and treatment of intrauterine anomalies. Operative hysteroscopy offers a wide variety of surgical procedures, e.g. hysteroscopic myomectomy, polypectomy, and hysteroscopic metroplasty. Endometrial ablation by Nd-YAG laser or resectoscope (roller ball and/or cutting loop) can be regarded as the gold standard for the treatment of women with menorrhagia wishing to avoid hysterectomy. Careful patient counseling and selection, endometrial thinning, and surgical skills are mandatory to achieve optimal results. References 1. Bozzini P. Der Lichtleiter oder Beschreibung einer einfachen Vorrichtung und ihrer Anwendung zur Erleuchtung innerer Höhlen und Zwischenräume des lebenden animalischen Körpers. Weimar: Landes-Industrie-Comptoir, Valle RF, Sciarra JJ. Hysteroscopy: a useful diagnostic adjunct in gynecology. Am J Obstet Gynecol 1975; 122: Sciarra JJ, Valle RF. Hysteroscopy: a clinical experience with 320 patients. Am J Obstet Gynecol 1977; 127: Taylor PJ, Cumming DC. Hysteroscopy in 100 patients. Fertil Steril 1979; 31: Barbot J, Parent B, Dubuisson JB. Contact hysteroscopy: another method of endoscopic examination of the uterine cavity. Am J Obstet Gynecol 1980; 136: Mencaglia L, Perino A, Hamou J. Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding. J Reprod Med 1987; 32: Seinera P, Maccario S, Visentin L, DiGregorio A. Hysteroscopy in an IVF-ER program. Clinical experience with 360

8 780 F. Wieser et al. infertile patients. Acta Obstet Gynecol Scand 1988; 67: de Jong P, Doel F, Falconer A. Outpatient diagnostic hysteroscopy. Br J Obstet Gynaecol 1990; 97: Downes E, al-azzawi F. How well do perimenopausal patients accept outpatient hysteroscopy? Visual analogue scoring of acceptability and pain in 100 women. Eur J Obstet Gynecol Reprod Biol 1993; 48: Downes E, al-azzawi F. The predictive value of outpatient hysteroscopy in a menopause clinic. Br J Obstet Gynaecol 1993; 100: Nagele F, Kurz C, Benes K, Pateisky N. Initial experiences with ambulatory irrigation hysteroscopy. Geburtshilfe Frauenheilkd 1995; 55: Nagele F, O Connor H, Davies A, Badawy A, Mohamed H, Magos A. Two thousand five hundred outpatient diagnostic hysteroscopies. Obstet Gynecol 1996; 88: Towbin NA, Gviazda IM, March CM. Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding. Am J Obstet Gynecol 1996; 174: Kremer C, Barik S, Duffy S. Flexible outpatient hysteroscopy without anesthesia: a safe, successful and well tolerated procedure. Br J Obstet Gynaecol 1998; 105: Wieser F, Albrecht A, Kurz C, Wenzl R, Nagele F. Ambulatory hysteroscopy in evaluation of postmenopausal bleeding. Wien Klin Wochenschr 1999; 111: Ceci O, Bettocchi S, Marello F, Di Venere R, Pellegrino AR, Laricchia L et al. Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen. J Am Assoc Gynecol Laparosc 2000; 7: Hald F, Kristoffersen SE, Gregersen E. Prostaglandin vaginal suppositories in non pregnant women requiring cervical dilatation prior to hysteroscopy. Acta Obstet Gynecol Scand 1988; 67: Broadbent JA, Hill NC, Molnar BG, Rolfe KJ, Magos AL. Randomized placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy. Br J Obstet Gynaecol 1992; 99: Vercellini P, Colombo A, Mauro F, Oldani S, Bramante T, Crosignani PG. Paracervical anesthesia for outpatient hysteroscopy. Fertil Steril 1994; 62: Akkad AA, Habiba MA, Ismail N, Abrams K, al-azzawi F. Abnormal uterine bleeding on hormone replacement: the importance of intrauterine structural abnormalities. Obstet Gynecol 1995; 86: Zupi E, Luciano AA, Valli E, Marconi D, Maneschi F, Romanini C. The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy. Fertil Steril 1995; 63: Nagele F, O Connor H, Baskett TF, Davies A, Mohammed H, Magos AL. Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: a comparison with postmenopausal bleeding. Fertil Steril 1996; 65: Nagele F, Bournas N, O Connor H, Broadbent M, Richardson R, Magos AL. A comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy. Fertil Steril 1996; 65: Cicinelli E, Didonna T, Ambrosi G, Schonauer LM, Fiore G, Matteo MG. Topical anaesthesia for diagnostic hysteroscopy and endometrial biopsy in postmenopausal women: a randomised placebo-controlled double-blind study. Br J Obstet Gynaecol 1997; 104: Nagele F, Lockwood G, Magos AL. Randomized placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study. Br J Obstet Gynaecol 1997; 104: Davies A. Lignocaine aerosol spray in outpatient hystero- scopy: a randomized double-blind placebo-controlled trial. Fertil Steril 1997; 67: Wieser F, Kurz C, Wenzl R, Albrecht A, Huber JC, Nagele F. Atraumatic cervical passage at outpatient hysteroscopy. Fertil Steril 1998; 69: Tahir MM, Bigrigg MA, Browning JJ, Brookes ST, Smith PA. A randomized controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. Br J Obstet Gynaecol 1999; 106: Preutthipan S, Herabutya Y. A randomized controlled trial of vaginal misoprostol for cervical priming before hysteroscopy. Obstet Gynecol 1999; 94: Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. BMJ 2000; 320: Soriano D, Ajaj S, Chuong T, Deval B, Fauconnier A, Darai E. Lidocaine spray and outpatient hysteroscopy: randomized placebo-controlled trial. Obstet Gynecol 2000; 96: Wong AY, Wong K, Tang LC. Stepwise pain score analysis of the effect of local lignocaine on outpatient hysteroscopy: a randomized, double-blind, placebo-controlled trial. Fertil Steril 2000; 73: Giorda G, Scarabelli C, Franceschi S, Campagnutta E. Feasibility and pain control in outpatient hysteroscopy in postmenopausal women: a randomized trial. Acta Obstet Gynecol Scand 2000; 79: Unfried G, Wieser F, Albrecht A, Kaider A, Nagele F. Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial. Hum Reprod 2001; 16: Pal L, Lapensee L, Toth TL, Isaacson KB. Comparison of office hysteroscopy, transvaginal ultrasonography and endometrial biopsy in evaluation of abnormal uterine bleeding. J Soc Laparoendosc Surg 1997; 1: Lindemann HJ. Proceedings: C02-hysteroscopy, its development and current application possibilities. Geburtshilfe Frauenheilkd 1974; 34: Valle RF. A Manual of Clinical Hysteroscopy. 1st ed. New York: Parthenon Publishing, 1998: Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96: Campo R, Van Belle Y, Rombauts L, Brosens I, Gordts S. Office mini-hysteroscopy. Hum Reprod Update 1999; 5: Gimpelson RJ. Office hysteroscopy. Clin Obstet Gynecol 1992; 35: Valle RF. Office hysteroscopy. Clin Obstet Gynecol 1999; 42: Marty R, Valle RF. Eight years experience performing procedures with flexible hysteroscopes. J Am Assoc Gynecol Laparosc 1995; 3: Ross JW. Numerous indications for office flexible minihysteroscopy. J Am Assoc Gynecol Laparosc 2000; 7: DeCherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61: Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988; 27: Bent AE, Ostergard DR. Endometrial ablation with the neodymium: Yag laser. Obstet Gynecol 1990; 75: Garry R, Erian J, Grochmal SA. A multi-centre collaborative study into the treatment of menorrhagia by Nd-YAG laser ablation of the endometrium. Br J Obstet Gynaecol 1991; 98:

9 Diagnostic and operative hysteroscopy Magos AL, Baumann R, Lockwood GM, Turnbull AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet 1991; 337: Daniell JF, Kurtz BR, Ke RW. Hysteroscopic endometrial ablation using the rollerball electrode. Obstet Gynecol 1992; 80: Erian MM, Goh JT. Transcervical endometrial resection. J Am Assoc Gynecol Laparosc 1996; 3: Garry R, Shelley-Jones D, Mooney P, Phillips G. Six hundred endometrial laser ablations. Obstet Gynecol 1995; 85: Vilos GA, Vilos EC, King JH. Experience with 800 hysteroscopic endometrial ablations. J Am Assoc Gynecol Laparosc 1996; 4: Istre O. Transcervical resection of endometrium and fibroids: the outcome of 412 operations performed over 5 years. Acta Obstet Gynecol Scand 1996; 75: O Connor H, Magos A. Endometrial resection for the treatment of menorrhagia. N Engl J Med 1996; 335: Phillips G, Chien PF, Garry R. Risk of hysterectomy after 1000 consecutive endometrial laser ablations. Br J Obstet Gynaecol 1998; 105: Hawe JA, Phillips AG, Chien PF, Erian J, Garry R. Cavaterm thermal balloon ablation for the treatment of menorrhagia. Br J Obstet Gynaecol 1999; 106: Das Dores GB, Richart RM, Nicolau SM, Focchi GR, Cordeiro VC. Evaluation of Hydro ThermAblator for endometrial destruction in patients with menorrhagia. J Am Assoc Gynecol Laparosc 1999; 6: Teirney R, Arachchi GJ, Fraser IS. Menstrual blood loss measured 5 6 years after endometrial ablation. Obstet Gynecol 2000; 95: Weisberg M, Goldrath MH, Berman J, Greenstein A, Krotec JW, Fronio L. Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia. J Am Assoc Gynecol Laparosc 2000; 7: Donnez J, Polet R, Rabinovitz R, Ak M, Squifflet J, Nisolle M. Endometrial laser intrauterine thermotherapy: the first series of 100 patients observed for 1 year. Fertil Steril 2000; 74: Nagele F, Rubinger T, Magos A. Why do women choose endometrial ablation rather than hysterectomy? Fertil Steril 1998; 69: Donnez J, Nisolle M. Hysteroscopic surgery. Curr Opin Obstet Gynecol 1992; 4: Magos AL, Baumann R, Turnbull AC. Transcervical resection of endometrium in women with menorrhagia. BMJ 1989; 298: Leake JF, Murphy AA, Zacur HA. Noncardiogenic pulmonary edema: a complication of operative hysteroscopy. Fertil Steril 1987; 48: Indman PD, Brooks PG, Cooper JM, Loffer FD, Valle RF, Vancaillie TG. Complications of fluid overload from resectoscopic surgery. J Am Assoc Gynecol Laparosc 1998; 5: Bhattacharya S, Cameron IM, Parkin DE, Abramovich DR, Mollison J, Pinion SB et al. A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia. Br J Obstet Gynaecol 1997; 104: Garry R. Good practice with endometrial ablation. Obstet Gynecol 1995; 86: Magos A. Endometrial ablation. 1st ed. London: Churchill Livingstone, Overton C, Hargreaves J, Maresh M. A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study. Minimally Invasive Surgical Techniques Laser, EndoThermal or Endorescetion. Br J Obstet Gynaecol 1997; 104: Donnez J, Vilos G, Gannon MJ, Stampe-Sorensen S, Klinte I, Miller RM. Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large randomized, double-blind study. Fertil Steril 1997; 68: Sculpher M, Thompson E, Brown J, Garry R. A cost effectiveness analysis of goserelin compared with danazol as endometrial thinning agents. Br J Obstet Gynaecol 2000; 107: Fraser IS, Healy DL, Torode H, Song JY, Mamers P, Wilde F. Depot goserelin and danazol pre-treatment before rollerball endometrial ablation for menorrhagia. Obstet Gynecol 1996; 87: Sculpher MJ, Bryan S, Dwyer N, Hutton J, Stirrat GM. An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia. Br J Obstet Gynaecol 1993; 100: Dwyer N, Hutton J, Stirrat GM. Randomized controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 1993; 100: Brooks PG, Clouse J, Morris LS. Hysterectomy vs. resectoscopic endometrial ablation for the control of abnormal uterine bleeding. A cost-comparative study. J Reprod Med 1994; 39: Pinion SB, Parkin DE, Abramovich DR, Naji A, Alexander DA, Russell IT et al. Randomised trial of hysterectomy, endometrial laser ablation, and transcervical endometrial resection for dysfunctional uterine bleeding. BMJ 1994; 309: Alexander DA, Naji AA, Pinion SB, Mollison J, Kitchener HC, Parkin DE et al. Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects. BMJ 1996; 312: Cooper KG, Parkin DE, Garratt AM, Grant AM. A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss. Br J Obstet Gynaecol 1997; 104: Crosignani PG, Vercellini P, Mosconi P, Oldani S, Cortesi I, De Giorgi O. Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. Obstet Gynecol 1997; 90: Hidlebaugh DA, Orr RK. Long-term economic evaluation of resectoscopic endometrial ablation versus hysterectomy for the treatment of menorrhagia. J Am Assoc Gynecol Laparosc 1998; 5: Meyer WR, Walsh BW, Grainger DA, Peacock LM, Loffer FD, Steege JF. Thermal balloon and rollerball ablation to treat menorrhagia: a multicenter comparison. Obstet Gynecol 1998; 92: Grant A. Aberdeen Endometrial Ablation Trials Group. A randomized trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Br J Obstet Gynaecol 1999; 106: Vercellini P, Oldani S, Yaylayan L, Zaina B, De Giorgi O, Crosignani PG. Randomized comparison of vaporizing electrode and cutting loop for endometrial ablation. Obstet Gynecol 1999; 94: Gervaise A, Fernandez H, Capella-Allouc S, Taylor S, Vieille SL, Hamou J et al. Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding. Hum Reprod 1999; 14: Cooper KG, Bain C, Parkin DE. Comparison of microwave endometrial ablation and transcervical resection of the endometrium for treatment of heavy menstrual loss: a randomised trial. Lancet 1999; 354: Grainger DA, Tjaden BL, Rowland C, Meyer WR. Ther-

10 782 F. Wieser et al. mal balloon and rollerball ablation to treat menorrhagia: two-year results of a multicenter, prospective, randomized, clinical trial. J Am Assoc Gynecol Laparosc 2000; 7: Corson SL, Brill AI, Brooks PG, Cooper JM, Indman PD, Liu JH et al. One-year results of the vesta system for endometrial ablation. J Am Assoc Gynecol Laparosc 2000; 7: London R, Holzman M, Rubin D, Moffitt B. Payer cost savings with endometrial ablation therapy. Am J Manag Care 1999; 5: O Connor H, Broadbent JA, Magos AL, McPherson K. Medical Research Council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia. Lancet 1997; 349: Spaulding LB. Endometrial ablation for refractory postmenopausal bleeding with continuous hormone replacement therapy. Fertil Steril 1994; 62: Phillips DR. Endometrial ablation for postmenopausal uterine bleeding induced by hormone replacement therapy. J Am Assoc Gynecol Laparosc 1995; 2: Unger JB, Meeks GR. Hysterectomy after endometrial ablation. J Obstet Gynaecol 1996; 175: Sinervo K, Martyn P. Endometrial stromal sarcoma diagnosed after hysteroscopic endometrial resection. J Am Assoc Gynecol Laparosc 2000; 7: Colafranceschi M, Bettocchi S, Mencaglia L, van Herendael BJ. Missed hysteroscopic detection of uterine carcinoma before endometrial resection: report of three cases. Gynecol Oncol 1996; 62: Copperman AB, DeCherney AH, Olive DL. A case of endometrial cancer following endometrial ablation for dysfunctional uterine bleeding. Obstet Gynecol 1993; 82: Ramey JW, Koonings PP, Given FT Jr, Acosta AA. The process of carcinogenesis for endometrial adenocarcinoma could be short: development of a malignancy after endometrial ablation. Am J Obstet Gynecol 994; 170: Pugh CP, Crane JM, Hogan TG. Successful intrauterine pregnancy after endometrial ablation. J Am Assoc Gynecol Laparosc 2000; 7: McLucas B. Pregnancy after endometrial ablation. A case report. J Reprod Med 1995; 40: Droegenmueller W, Greer BE, Makowski EL. Preliminary observations of cryocoagulation of the endometrium. Am J Obstet Gynecol 1970; 107: Romer T, Muller J. A simple method of coagulating endometrium in patients with therapy-resistant, recurring hypermenorrhea. J Am Assoc Gynecol Laparosc 1999; 6: Bustos-Lopez HH, Baggish M, Valle RF, Vadillo-Ortega F, Ibarra V, Nava G. Assessment of the safety of intrauterine instillation of heated saline for endometrial ablation. Fertil Steril 1998; 69: Amso NN, Stabinsky SA, McFaul P, Blanc B, Pendley L, Neuwirth R. Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group. Br J Obstet Gynaecol 1998; 105: Friberg B, Persson BR, Willen R, Ahlgren M. Endometrial destruction by hyperthermia a possible treatment of menorrhagia. An experimental study. Acta Obstet Gynecol Scand 1996; 75: Goldrath MH, Barrionuevo M, Husain M. Endometrial ablation by hysteroscopic instillation of hot saline solution. J Am Assoc Gynecol Laparosc 1997; 4: Richart RM, das Dores GB, Nicolau SM, Focchi GR, Cordeiro VC. Histologic studies of the effects of circu- lating hot saline on the uterus before hysterectomy. J Am Assoc Gynecol Laparosc 1999; 6: Fernandez H, Capella S, Audibert F. Uterine thermal balloon therapy under local anaesthesia for the treatment of menorrhagia: a pilot study. Hum Reprod 1997; 12: Brooks PG. A clinical comparison between hydrothermablation and rollerball ablation to treat menorrhagia: a multicenter clinical trial. Obstet Gynecol 2000; 95: S Kremer C, Duffy S. Endometrial ablation: the next generation. Br J Obstet Gynaecol 2000; 107: Erian J. Endometrial ablation in the treatment of menorrhagia. Br J Obstet Gynaecol 1994; 101: Kitchener HC. A Scottish audit of hysteroscopy surgery for menorrhagia: complications and follow-up. Br J Obstet Gynaecol 1995; 102: Sculpher MJ, Dwyer N, Byford S, Stirrat GM. Randomised trial comparing hysterectomy and transcervical endometrial resection: effect on health related quality of life and costs two years after surgery. Br J Obstet Gynaecol 1996; 103: Chullapram T, Song JY, Fraser IS. Medium-term followup of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol 1996; 88: Jourdain O, Joyeux P, Lajus C, Sfaxi I, Harle T, Roux D et al. Endometrial Nd-YAG laser ablation by hysterofibroscopy: long-term results of 137 cases. Eur J Obstet Gynecol Reprod Biol 1996; 69: Crosignani PG, Vercellini P, Apolone G, De Giorgi O, Cortesi I, Meschia M. Endometrial resection versus vaginal hysterectomy for menorrhagia: long-term clinical and quality-of-life outcomes. Am J Obstet Gynecol 1997; 177: Tsaltas J, Taylor N, Healey M. A 6-year review of the outcome of endometrial ablation. Aust N Z J Obstet Gynaecol 1998; 38: Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol 1999; 94: Vercellini P, Zaina B, Yaylayan L, Pisacreta A, De Giorgi O, Crosignani PG. Hysteroscopic myomectomy: longterm effects on menstrual pattern and fertility. Obstet Gynecol 1999; 94: Neuwirth RS, Amin HK. Excision of submucous fibroids with hysteroscopic control. Am J Obstet Gynecol 1976; 126: Hallez JP, Netter A, Cartier R. Methodical intrauterine resection. Am J Obstet Gynecol 1987; 156: Loffer FD. Removal of large symptomatic intrauterine growths by the hysteroscopic resectoscope. Obstet Gynecol 1990; 76: Donnez J, Gillerot S, Bourgonjon D, Clerckx F, Nisolle M. Neodymium: YAG laser hysteroscopy in large submucous fibroids. Fertil Steril 1990; 54: Derman SG, Rehnstrom J, Neuwirth RS. The long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas. Obstet Gynecol 1991; 77: Hucke J, Campo RL, De Bruyne F, Freikha AA. Hysteroscopic resection of submucous myoma. Geburtshilfe Frauenheilkd 1992; 52: Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993; 81: 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: Goldenberg M, Sivan E, Sharabi Z, Bider D, Rabinovici J, Seidman DS. Outcome of hysteroscopic resection of