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Hysteroscopy
Updated: Aug 15, 2018
Author: John C Petrozza, MD; Chief Editor: Michel E Rivlin, MD

Overview

Background
Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. The basic
hysteroscope is a long, narrow telescope connected to a light source to illuminate the area to be visualized. With a patient in the
lithotomy position, the cervix is visualized by placing a speculum in the vagina. The distal end of the telescope is passed into a
dilated cervical canal, and, under direct visualization, the instrument is advanced into the uterine cavity. A camera is commonly
attached to the proximal end of the hysteroscope to broadcast the image onto a large video screen. Other common modifications
are inflow and outflow tracts included in the shaft of the telescope for fluids. Media, such as sodium chloride solution, can be
pumped through a hysteroscope to distend the endometrial cavity, enabling visualization and operation in an enlarged area.

Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical
problems. Hysteroscopic polypectomy, myomectomy, and endometrial ablation are just a few of the commonly performed
procedures. Given their safety and efficacy, diagnostic and operative hysteroscopy have become standards in gynecologic
practice.

Equipment

Hysteroscopes

The telescope consists of 3 parts: the eyepiece, the barrel, and the objective lens. The focal length and angle of the distal tip of
the instrument are important for visualization (as are the fiberoptics of the light source).

Angle options include 0°, 12°, 15°, 25°, 30°, and 70°. A 0° hysteroscope provides a panoramic view, whereas an angled one might
improve the view of the ostia in an abnormally shaped cavity.

Hysteroscopes are available in different styles, including rigid and flexible (used most commonly in clinical settings)
hysteroscopes, contact hysteroscopes, and microcolpohysteroscopes. The diameter of each instrument varies and is an important
consideration. The requirement of a sheath for input-outflow of distention media increases the size of the hysteroscope.

Rigid hysteroscopes

Rigid hysteroscopes are the most commonly used instruments. Their wide range of diameters allows for in-office and complex
operating-room procedures. Of the narrow options (3-5 mm in diameter), the 4-mm scope offers the sharpest and clearest view. It
accommodates surgical instruments but is small enough to require minimal cervical dilation. In addition, patients tolerate this
instrument well with only paracervical block anesthesia.

Rigid scopes larger than 5 mm in diameter (commonly 8-10 mm) require increased cervical dilation for insertion. Therefore, they
are most frequently used in the operating room with intravenous (IV) sedation or general anesthesia. Large instruments include
an outer sheath to introduce and remove media and to provide ports to accommodate large and varied surgical instruments.

Flexible hysteroscopes

The flexible hysteroscope is most commonly used for office hysteroscopy. It is notable for its flexibility, with a tip that deflects over
a range of 120-160°. Its most appropriate use is to accommodate the irregularly shaped uterus and to navigate around
intrauterine lesions. It is also used for diagnostic and operative procedures.

During insertion, the flexible contour accommodates to the cervix more easily than does a rigid scope of a similarly small
diameter. The view was initially described as having a ground-glass quality, which was markedly less desirable than the view
obtained with rigid scopes.[1] New, digitally enhanced scopes now offer similar image quality to a rigid hysteroscope lens.

Light source

Each hysteroscope is attached to an internal or external light source for illumination at the distal tip. Energy sources include
tungsten, metal halide, and xenon. A xenon light source with a liquid cable is considered the superior option.[2, 3]
Surgical instruments

Surgical instruments are available in both rigid and flexible forms to be inserted through the operating channels of the scopes.
Examples of surgical instruments and their uses are listed below:

Scissors - To incise a septum, excise a polyp, or lyse synechiae

Biopsy forceps - To perform directed biopsy for pathologic review

Grasping instruments - To remove foreign bodies

Roller ball, barrel, or ellipsoid - To perform endometrial ablation and/or desiccation (This instrument is used with a
resectoscope.)

Loop electrode - To resect a fibroid or polyp or endometrium (This instrument is used with a resectoscope.)

Scalpel - To cut or coagulate tissue, with high power density at its tip (This instrument is used with a resectoscope.)

Vaporizing electrodes – To destroy endometrial polyps, fibroids, intrauterine adhesions, and septa; also used for
endometrial ablation (This instrument is used with a resectoscope.)

Morcellator – To cut and remove endometrial polyps or fibroids

Improvements in hysteroscope design have improved the effectiveness of the inflow-outflow channels and of specific operating
instruments. For example, the Chip E-Vac System (Richard Wolf Medical Instruments Corporation, Vernon Hill, Ill) incorporates a
suction channel and a pump to aid in removing chips of tissue during resection. This feature improves visibility and may decrease
time otherwise spent emptying the pieces from the endometrial cavity.

Another instrument in the forefront is a hysteroscopic morcellator (Smith & Nephew, Inc, Andover, Mass), which may reduce
myomectomy and polypectomy time by morcellating and removing tissue in 1 movement under direct visualization. It requires
cervical dilation to 9 mm. A new hysteroscopic morcellating system called MyoSure (Interlace Medical, Inc, Framingham, Mass) is
reported to work just as well, removing submucosal fibroids up to 3 cm in diameter, with a unit that only requires cervical dilation
to 6 mm. This smaller diameter suggests it may be used in an office setting.

Energy sources and uses

Monopolar and bipolar electricity, as well as laser energy, all have uses in hysteroscopy.

Monopolar cautery

The resectoscope is a specialized instrument often used with a monopolar, double-armed electrode and a trigger device for use in
hypotonic, nonconductive media, such as glycine. It cuts and coagulates tissue by means of contact desiccation with resistive
heating.[4] The depth of thermal damage is based on several factors: endometrial thickness; speed, pressure, and duration of
contact during motion; and power setting.[5, 4]

A thin electrode can cut tissue, whereas one with a large surface area, such as a ball or barrel, is best suited for coagulation.[6]

Bipolar cautery

The VersaPoint system (Gynecare, Inc, Somerville, NJ), uses bipolar circuitry for electrosurgery, which can be performed in
isotonic conductive media. This system includes a spring tip for hemostatic vaporization of large areas, a ball tip for precise
vaporization, and a twizzle tip for hemostatic resection and morcellation of tissue. There is also a cutting loop similar to traditional
resectoscopy.[4]

Bipolar resectoscopes have been designed by both Karl Storz (Tuttlingen, Germany) and Richard Wolf Medical Instruments
Corporation (Vernon Hill, Ill). The latter has developed the Princess (Petite Resectoscope Including E-Line and S-Line Systems),
a 7 mm resectoscope — the smallest bipolar resectoscope available. In addition, the Chip E-Vac System (Richard Wolf Medical
Instruments Corporation, Vernon Hill, Ill) can be used with bipolar and monopolar energy.

Laser techniques

Several fiberoptic lasers are available for gynecologic use, including potassium-titanyl-phosphate (KTP), argon, and Nd:YAG
lasers. They all have different wavelengths, though the KTP and argon lasers have similar properties.

Media
The use of media is critical for panoramic inspection of the uterine cavity. The medium opens the potential space of the otherwise
narrow uterine cavity. Intrauterine pressures needed to adequately view the endometrium are proportional to the muscle tone and
thickness of the uterus. The refractive index of each medium affects magnification and visualization of the endometrium.

Gases

Carbon dioxide (CO2) is rapidly absorbed and easily cleared from the body by respiration. The refractory index of CO2 is 1.0,
which allows for excellent clarity and widens the field of view at low magnification. The gas easily flows through narrow channels
in small-diameter scopes, making it useful for office-based diagnostic hysteroscopy. However, this method offers no way to clear
blood from the scope.

With CO2, a hysteroscopic insufflator is required to regulate flow and limit maximal intrauterine pressure. (Note that laparoscopic
insufflators are not safe.) A flow rate to 40-60 mL/min at a maximum pressure of 100 mm Hg is generally accepted as safe.
Pressures and rates higher than this can result in cardiac arrhythmias, embolism, and arrest.[2]

Fluids

The advantage of fluid over gas is the symmetric distention of the uterus with fluid and its effective ability to flush blood, mucus,
bubbles, and small tissue fragments out of the visual field. Both low-viscosity and high-viscosity fluid media can be used for
distention. A pressure of 75 mm Hg is usually adequate for uterine distention; rarely is more than 100 mm Hg required, and
pressures higher than this can increase the risk of intravasation of medium.[7]

Various delivery systems are designed to suit the many media used for uterine distention and to accurately record volumes of
inflow and outflow. This recording is important because fluid can leave the uterus by means of intended efflux systems, cervical or
tubal leakage, or intravasation. Preventing excess absorption of hypotonic fluids is essential for patient safety. The simplest
delivery system is a syringe that most often is used with high-viscosity Dextran 70. Hanging, gravity-fed containers to deliver low-
viscosity fluids can be raised or compressed with a cuff; however, these can be unreliable in estimating intrauterine pressures.
Pumps are available to monitor pressure and volume for low-viscosity media. Media then usually flows into the uterine cavity
through an inner sheath around the hysteroscope. A perforated outer sheath is used for collection or efflux of media. This design
creates laminar flow, which keeps the visual field clear.[1]

As noted above, new, sophisticated efflux mechanisms have been designed to improve the clearance of both blood and
particulate matter from the operating space. Closed systems actively return fluid to a pump reservoir, whereas open systems
allow free flow of the medium out the cervix into a collection bag for volume monitoring.

0.9% sodium chloride solution and lactated Ringer solution

Normal sodium chloride solution and lactated ringer solution are isotonic, conductive, low-viscosity fluids that can be used for
diagnostic hysteroscopy and for limited operative procedures. Surgical procedures using mechanical, laser, monopolar (only with
the ERA sleeve or Opera Star systems), and bipolar energy (VersaPoint system) are safe (see Surgical instruments and Energy
sources and uses above).

Two major disadvantages associated with these solutions include (1) their miscibility with blood, which obscures visibility with
bleeding, leading to the need for increased volumes to clear the operative field, and (2) their excellent conductivity, which
precludes procedures that use standard monopolar electrosurgery.

5% Mannitol, 3% sorbitol, and 1.5% glycine

The hypotonic, nonconductive, low-viscosity fluids 5% mannitol, 3% sorbitol, and 1.5% glycine improve visualization when
bleeding occurs. They can be used in diagnostic as well as operative hysteroscopy. (Note that 5% mannitol can be used only with
monopolar operative procedures.)

All impose a risk of volume overload and hyponatremia from intravascular absorption (particularly > 2 L). Therefore, careful fluid
monitoring is required during their use. When intravasation of 5% mannitol occurs, it stays in the extracellular compartment;
treatment of this condition is discontinuing the procedure and administering diuretics.[7] 3% sorbitol is broken down into fructose
and glucose and therefore has an added risk of hyperglycemia when absorbed in excess. Use 1.5% glycine with caution in
patients with impaired hepatic function because glycine is metabolized to ammonia.

Dextran 70

The only high-viscosity medium available, Dextran 70 (Hyskon; Pharmacia Laboratories, Piscataway, NJ) is a nonelectrolytic,
nonconductive fluid that can be used in all types of procedures. It is immiscible with blood and minimally leaks through the cervix
and tubes, allowing for excellent visibility during surgical procedures.

Like the other nonelectrolytic fluids, however, prevent absorption of more than 500 mL to avoid fluid overload. With each 100 mL
of Dextran 70 absorbed, the intravascular volume increases by 800 mL.[7, 8] Allergic reactions and anaphylaxis, fluid overload,
disseminated intravascular coagulopathy, and destruction of instruments are adverse effects of this medium.

History of the Procedure

The development of hysteroscopy is rooted in the work of Pantaleoni, who first reported uterine endoscopy in 1869.[7] However,
at that time, instrumentation was elementary, and expansion of the uterine cavity was insufficient. In 1925, Rubin first used CO2 to
distend the uterus.[7] Around the same time, Gauss was experimenting with the use of fluids to achieve uterine expansion.

Hysteroscopy did not become popular until the 1970s, when technology afforded more practical and usable instruments than
before (see Hysteroscopes above). The use of liquid distention media became routine by the 1980s, and many new hysteroscopic
procedures, including endometrial ablation, were developed.[7] Initially used by urologists for transurethral resection of the
prostate, the resectoscope was modified for hysteroscopic procedures, allowing for resection of intrauterine pathology with
monopolar cautery. By the mid-1980s, hysteroscopic procedures had nearly replaced dilation and curettage (D&C) for diagnosing
intrauterine pathology.[9]

Over the past few decades, refinements in optic and fiberoptic technology and inventions of new surgical accessories have
dramatically improved visual resolution and surgical techniques in hysteroscopy. Many hysteroscopic procedures have replaced
old, invasive techniques. Now, as instruments become smaller than before, office hysteroscopy is replacing operating-room
procedures. One of the most recent hysteroscopic procedures is female sterilization (Essure, Conceptus, Incorporated, Mountain
View, Calif), which can be performed in the gynecologist's office. Novel instruments and techniques continue to emerge, and the
prospects for improvement seem unlimited.

In July 2018, Bayer announced that they will stop selling and distributing the Essure device in the United States after December
31, 2018 due to declining sales of the product.[10]

In April of 2018, the U.S. Food and Drug Administration ordered restrictions to the sale and distribution of the Essure permanent
contraceptive device in order to ensure that all women are provided with adequate risk information so that they can make
informed decisions whether to use the permanent contraceptive.[11]

Indications
Abnormal uterine bleeding

Hysteroscopy has nearly replaced standard D&C for the management of abnormal uterine bleeding (AUB), as it allows for direct
visualization and diagnosis of intrauterine abnormalities, and it often offers an opportunity for simultaneous treatment.[12, 13]

To diagnose the cause of AUB, a full workup is required to rule out endocrine or hormonal disorders, benign lesions,
premalignant, or malignant pathology. Uterine sampling can be done by means of endometrial biopsy, D&C, or direct visualization
with hysteroscopy and specific biopsy procedures. Evaluation of the uterine cavity with sonohysterography or diagnostic
hysteroscopy is up to 88% effective in identifying polyps and submucosal fibroids.[14, 15]

Hysteroscopic diagnosis of intracavitary abnormalities in women with AUB carries a sensitivity of 94% and specificity of 89%[16]
and compares favorably with the accuracy of saline infusion sonography, which has a reported 95% sensitivity and 88%
specificity.[17] Of note, the diagnostic accuracy of hysteroscopy for endometrial cancer is also high with an overall sensitivity of
86.4% and specificity of 99.2%.[18] Some consider MRI useful for evaluating intrauterine pathology, but MRI is a relatively
expensive test.[19]

For patients with AUB for whom fertility is not an issue, in whom no endocrine or hormonal cause is isolated, and in whom
endometrial atypia or malignancy is ruled out, endometrial ablation has become an acceptable alternative to hysterectomy. In the
short term, ablation for a benign disorder results in amenorrhea in approximately 30% of patients.[20, 8, 21] Studies show that
approximately 26% of patients have spotting after ablation, 34% have a decreased flow, and 10% have no change or increased
symptoms.[8] The same data suggested that the long-term effectiveness of endometrial ablation for menorrhagia or fibroids is 60-
90%, with 90% of patients noting an overall decrease in flow and amenorrhea, which occurs in 30-50%.[22]

Reported reoperation rates after endometrial ablation (resectoscope, vaporization or thermal balloon method) have been reported
to be as high as 38% at 5 years.[23] Review including only first generation endometrial ablation techniques estimated that 6-20%
of women require further surgery for control of menorrhagia after 1-5 years of follow-up.[24] Patients who are taking estrogen still
require progesterone for endometrial protection from estrogen-induced endometrial changes.[14, 25]

Infertility
Hysteroscopy is not part of the routine workup for infertility, but when compared with hysterosalpingography, hysteroscopy is
equivalent for evaluating the uterine cavity, and it increases accuracy in diagnosing the cause of intrauterine filling defects.[1] In
unexplained infertility, hysteroscopy may be performed simultaneously with laparoscopy to evaluate the uterine cavity and cervix.
[26, 27]

Intracavitary lesions are implicated as causes of infertility, and their removal may increase fertility. However, literature supporting
the significance of this association is scant. Overall, pregnancy rates of 50-78% in previously infertile women have been reported
after hysteroscopic polypectomy.[28, 29, 30, 31, 32] Pregnancies were conceived spontaneously or with the use of intrauterine
insemination or in vitro fertilization. The only randomized control trial comparing pregnancy rates after polypectomy versus no
treatment in infertile women concluded hysteroscopic polypectomy prior to IUI increased the odds of pregnancy, with a relative
risk of 2.1 (95% CI, 1.5-2.9). Of note, 65% of the women who were randomized to polypectomy became pregnant prior to the first
IUI.[30]

The effect of hysteroscopic polypectomy on IVF also remains unclear. In general, studies have suggested that hysteroscopic
removal of lesions < 2 cm does not adversely affect an IVF cycle.[33, 34, 35]

The incidence of myomas in women without another obvious etiology for infertility is small, estimated to be 1-2.4%.[36] The effect
of myomas on reproduction is not definitive but it is generally accepted that fibroids causing distortion of the endometrial cavity
may adversely influence fertility.[37] Location, size of myomas, and coexisting fertility diagnoses are believed to be major
considerations when determining management options.

Surgical management with hysteroscopic myomectomy has been reported to yield pregnancy rates of 16.7-76.9% (mean of 45%)
in infertile women.[36, 38] However, no randomized controlled trials examine the effect of hysteroscopic myomectomy on fertility,
and pregnancy rate estimates come from retrospective and small prospective studies with large variations in study populations
and design. Debate also exists in regard to management of small myomas with minimal uterine cavity distortion.

For patients with recurrent miscarriage and intracavitary fibroids, surgery increases rates of viable pregnancy outcomes.[39]

Myomas may adversely affect outcomes for women undergoing IVF but there again remains no definitive consensus on
management of fibroids prior to an IVF attempt. A negative impact of submucosal fibroids on pregnancy rates has been
demonstrated in 3 separate meta-analyses.[40, 36, 41] Intramural fibroids have also been reported to have a significant negative
influence on pregnancy rates.[42, 41] However, other meta-analyses have not supported the association.[40, 36] Furthermore, a
meta-analysis of 2 retrospective studies available in the literature examining hysteroscopic myomectomy suggests that the
procedure does not negatively affect pregnancy rates in IVF cycles.[41]

Intrauterine adhesions

Asherman syndrome was identified in 1948 as uterine synechiae.[43] These intrauterine adhesions (IUA) are often associated
with amenorrhea or infertility. The prevalence rate of IUAs in the general population is 1.5%, with adhesions noted in up to 30% of
women undergoing hysteroscopy following 3 or more spontaneous abortions treated with dilation and curettage.[44] Hysteroscopy
is the gold standard used to diagnose and treat these adhesions. Benefits include visually directed lysis. Filmy adhesions are
often lysed by distention alone, whereas the dense adhesions often require cutting or excision with blunt, sharp, electrocautery, or
laser techniques.[2] Fluoroscopic guidance can also be used to assist in restoration of the uterine cavity.[45]

If the patient's symptoms include abnormal bleeding, hysteroscopic treatment results in an 88-98% return to normal menstrual
cycles.[14, 22] If no other infertility issues are present, 79% of treated patients have normal pregnancies (ie, 75% of those with
mild disease but only 31% with severe adhesions).[14]

Reformation of adhesions may have a significant impact on the conception rate after hysteroscopic adhesiolysis. Conception
rates in women with recurrence of adhesions after initial hysteroscopic adhesiolysis have been found to be significantly lower than
in women with demonstration of a normal uterine cavity on second look hysteroscopy (11.8% vs 59.1%). Of consideration,
hysteroscopic treatment may also increase the risk of abnormal placentation (eg, accreta, percreta, increta, previa).

Müllerian anomalies
Approximately 1-2% of all women, 4% of infertile women, and 10-15% of patients with recurrent miscarriage have müllerian
anomalies. These anomalies range from didelphys to müllerian agenesis. Uterine septum and in utero diethylstilbestrol (DES)
exposure are more likely to be associated with miscarriage than is uterus didelphys.[14] Patients with a bicornuate uterus have a
>50% live birth rate compared with those with a uterine septum, who have a < 30% live birth rate.[46] Patients with in utero DES
exposure are likely to have a T -shaped uterus with corneal restriction bands, pretubal bulges, lower-uterine-segment dilation, and
a small and irregular cavity with borders resembling adhesions.[14] Hysteroscopy can be used to confirm but not always to treat
these findings.

Septate uterus is the most common structural uterine anomaly, accounting for 35% of anomalies, and is associated with the
highest incidence of reproductive failure.[47] The diagnosis of septate uterus is made after excluding the diagnosis of a bicornuate
uterus. Once 2 hemicavities are visualized on imaging, the uterine fundus must be evaluated. Evidence of fundal indentation is an
indication of bicornuate uterus, whereas, a smooth fundus is present with uterine septum. HSG, transvaginal ultrasonography, 3-
dimensional ultrasonography, and MRI have all been used to make an accurate diagnosis but concurrent hysteroscopy and
laparoscopy remain the gold standard.[47]

Division of a uterine septum has historically been performed by laparotomy but is now most commonly performed via a
hysteroscopic approach. Edstrom reported the first hysteroscopic resection of a septum[1] and Bret and Guillet were the first to
recommend incising versus excising the septum.[46] Surgical complications are fewer with the hysteroscopic approach than with
other procedures, such as Jones, Strassman, or Tompkins metroplasty.[46] Of patients undergoing hysteroscopic resection for
müllerian anomalies, 20% have dysmenorrhea after surgery compared with 50% after abdominal procedures.[46] Rates of term-
pregnancy outcomes after hysteroscopic resection are equivalent to those of abdominal metroplasty for uterine septum.[14] Live
birth rates after treatment are as high as 80%.[22]

Significant improvements are seen in pregnancy outcomes following hysteroscopic metroplasty in women with recurrent
miscarriage. Pregnancy rates have been estimated to increase from 3% prior to surgery to approximately 80% after hysteroscopic
correction with a significant decrease in miscarriage rates.[48]

Although, a septate uterus is not a cause for infertility, the literature suggests women with a septate uterus and otherwise
unexplained infertility may benefit from metroplasty, but to a more modest extent.[49, 50] In comparison to women with
unexplained infertility and a normal uterine cavity, pregnancy rates have been shown to be significantly higher in women with a
septum after removal, 20.4% versus 38.6% (after 12 mo of follow-up). Live birth rates of 18.9% versus 34.1% were also reported.
[49]

Metroplasty should also be considered for women who plan to undergo IVF.[47] Retrospective review has also indicated that
pregnancy outcomes may improve with IVF after the incision of an incomplete septum, but continued investigation is needed.[51]

Polyps and fibroids

Endometrial polyps and fibroids are well known to cause irregular vaginal bleeding. Fibroids are the most common solid pelvic
tumor in women, found in 20% of women older than 35 years.[14] Menorrhagia due to symptomatic submucosal fibroids is the
most common indication for surgical intervention.[39] Other indications include infertility, dysmenorrhea, and pelvic pain.

Polyps and submucosal fibroids can be definitively diagnosed and effectively treated with hysteroscopy. Diagnosis of endometrial
polyps via hysteroscopy is 94% sensitive and 92% specific. For submucosal myomas, diagnostic hysteroscopy is 87% sensitive
and 95% specific.[16] Only 16% of treated patients require further surgery.[3]

When AUB is present, polypectomy has been reported to successfully alleviate symptoms 75-100% of the time.[52] Initial
hysteroscopy is estimated to successfully remove fibroids in 85-95% of cases, with additional surgery required in approximately 5-
15%.[53] Recurrence of symptoms after hysteroscopic myomectomy is most common with large uteri and numerous and deep
fibroids.[54, 39]

The advantages of hysteroscopic resection are numerous and include treating irregular bleeding and obtaining tissue diagnosis;
for myomectomy, benefits include avoiding laparotomy, uterine incision, and hospital stays. If a fibroid is predominantly
submucosal, complete resection is possible. A 2-step procedure is sometimes needed to resect a fibroid that is partially intramural
or large.[19]

Some investigators report improved results and decreased adhesion rates after pretreatment with a gonadotropin-releasing
hormone (GnRH) agonist or medroxyprogesterone acetate (Depo-Provera) on the day of surgery,[14] while others report no
benefit and possibly increased difficulty of surgery.[55] Postoperative use of estrogen decreases adhesion formation.[14, 22]

In patients desiring to maintain fertility, hysteroscopic myomectomy is a reasonable option,[56, 57] and minimal cauterization
should be used to decrease damage to otherwise healthy endometrium.

Sterilization

Irreversible tubal sterilization can be accomplished transcervically with the Essure contraceptive tubal occlusion device and
delivery system (Conceptus Inc, Mountain View, Calif). The procedure is quick, with a total procedure time averaging 35 minutes
(Conceptus Inc). More recent studies report the total procedure to actually be less than 15 minutes.[58] There is no need for
abdominal incisions, recovery time is rapid, and successful bilateral placement at first attempt ranges from 83-94.1%. A second
attempt at placement may be needed, increasing successful placement to 96.7%.[58] Overall, the procedure carries a 4-year
effectiveness rate of 99.8% (Conceptus Inc).

Good visualization of the tubal ostia, placement during the proliferative phase of the menstrual cycle, and NSAID premedication
have all been significantly associated with successful placement.[59, 60, 58]

Confirmation of tissue ingrowth by further imaging is required 3 months after the procedure. HSG is currently the accepted and
recommend imaging modality, but transvaginal ultrasonography with or without contrast infusion has also been proposed.[61, 62,
63] A 2011 study of 118 women who had successful bilateral Essure placement found contrast infusion sonography to be a safe
and accurate confirmation test.[64] Bilateral tubal occlusion is seen at 3 months in 92% of women after the first attempt at
placement.[65] The procedure can be repeated a second time to ultimately achieve occlusion.

Additional contraceptive control is required until placement and tubal occlusion are confirmed. Pregnancy can occur after the
procedure with most reported pregnancies occurring in women with inadequate follow-up.[66] Additional explanations include
preprocedure pregnancy and misinterpretation of the HSG.

Adverse events include expulsion of the microinsert, tubal perforation, and delayed tubal occlusion. Procedural side effects
include a vasovagal response, cramping, dizziness, nausea, hypervolemia, and vaginal spotting.

Most importantly, the procedure is irreversible and should not be performed in women with uncertainly regarding desire for future
fertility.

In July 2018, Bayer announced that they will stop selling and distributing the Essure device in the United States after December
31, 2018 due to declining sales of the product.[10]

In April of 2018, the U.S. Food and Drug Administration ordered restrictions to the sale and distribution of the Essure permanent
contraceptive device in order to ensure that all women are provided with adequate risk information so that they can make
informed decisions whether to use the permanent contraceptive.[11]

A recently approved procedure, called Adiana, uses radiofrequency energy within the tubes, followed by insertion of a polymer
matrix to promote scarring. Compared to the Essure procedure, no portion of the device is left within the uterine cavity. Initial
failure rates seem higher than Essure at 4.9%, but more clinical studies are needed to confirm.

Proximal tubal obstruction

This diagnosis is difficult to make and is most often suggested by the failure of contrast to enter the fallopian tube on HSG. It may
be due to infection, intraluminal debris, salpingitis isthmica nodosum, or endometriosis. Many cases may simply be due to spasm.
[14] In theory, repair of proximal disease and removal of scar tissue is beneficial, and cannulation of the tubes can be performed
at the same time.[22] Up to 85% of occlusions can be treated with cannulation, but reocclusion occurs in approximately one third
of cases.[67] Tubal perforation is rare but could lead to further tubal pathology. No controlled studies have been conducted to
support the efficacy of hysteroscopic treatment of proximal tubal obstruction for infertility.

Intrauterine devices

Hysteroscopy can be applied to remove an intrauterine device (IUD) under direct visualization after sonography-guided retrieval
fails.[3]

Relevant Anatomy
For any hysteroscopic procedure, the surgeon must understand the thickness of the uterine wall. This knowledge allows the
surgeon to manipulate the surgery on the basis of the area of the uterus where he or she is operating. The table lists the wall
thicknesses for each area of the uterus. Remember that the uterus is longer and thicker in reproductive-aged women than in
postmenopausal women.

Table. Thickness of the Uterine Wall (Open Table in a new window)

Location Mean, mm Range, mm

Anterior wall 22.5 17-25

Posterior wall 21 15-25

Fundus 19.5 15-22

Isthmus 10 8-12

Corpus 5.5 4-7

Contraindications
In general, hysteroscopy is avoided in patients with the following findings:

Active cervical or uterine infection

A large uterine cavity, ie, longer than 10 cm in length (clinically similar to a 12-wk pregnant uterus) (However, this number
is variable and often depends on the patient's habitus.)

Severe medical conditions precluding surgery

Pregnancy

Concerns and contraindications for hysteroscopy depend on the procedure planned. For endometrial ablation, considerations
include a desire for future fertility, atypical endometrial hyperplasia or endometrial cancer, and undiagnosed abnormal bleeding.
Polypectomy and myomectomy, issues include transmural lesions, use of hypotonic media in patients with hyponatremia, use of
glycine in patients with liver disease, and use of sorbitol in patients with severe diabetes. In addition, if the uterus is deeper than
12 cm, the cavity may not distend appropriately.[68] If lesions are larger than 2 cm, patients must be counseled about possibility of
a staged procedure, increased fluid deficit, and blood loss.

Contraindications to transcervical sterilization with Essure include current pregnancy or pregnancy within 6 weeks of the
scheduled procedure, current or recent lower pelvic infection, allergy to contrast, hypersensitivity to nickel, or patients in whom
only one microinsert can be placed (tubal occlusion or uterine abnormalities impeding proper visualization).

Workup

Laboratory Studies
See the list below:

CBC: As in most surgical procedures, the CBC provides the surgeon with information regarding the patient's baseline
status and, if blood loss is encountered, with an idea of how much blood loss is acceptable. A blood count in the reference
range also ensures adequate oxygenation to all vital and healing tissues and an adequate immune response.

Blood typing and screening: With the risk of hemorrhage approaching 7-8% in some surgical hysteroscopic procedures, a
sample in the blood bank increases the efficiency of access to replacement blood products if needed.

Electrolyte determinations: In patients with medical disorders that predispose them to metabolic abnormalities (eg, diuretic
use), electrolytes should be tested preoperatively. Some surgeons routinely obtain baseline levels in case a significant
deficit of distention medium occurs (especially with a hyposmolar solution), whereas most obtain electrolyte levels
intraoperatively or postoperatively only if a clinically significant fluid deficit occurs. The ultimate decision should be based
on the type of case, the surgeon's skill, the suspected fluid absorption, and the ability to accurately ascertain fluid deficits in
the operating room.

Determination of human chorionic gonadotropin (hCG) levels: Determination of pregnancy status is mandatory in any
woman of reproductive age.

Cervical cultures: Depending on the prevalence of chlamydia and gonorrhea in the population, this may be a worthwhile
preoperative test. Also, if the patient is reporting a vaginal discharge, cultures and a wet smear for bacterial vaginosis and
trichomoniasis are recommended.

Papanicolaou test (Pap smear): A normal finding on Pap smear, or at least an abnormal finding on Pap smear that has
been appropriately evaluated, is required because trauma to the cervix may alter the appearance of any abnormalities.

Imaging Studies
See the list below:

Hysterosalpingogram or sonohysterogram: For evaluating the uterine cavity and patency of fallopian tubes,
hysterosalpingography is the superior study. However, to selectively look at the uterine cavity, sonohysterography or saline-
infused sonography are superior. They have better negative and positive predictive values than those of
hysterosalpingogram in determining the location and size of fibroids and endometrial polyps and for ascertaining the
presence of most uterine anomalies, including septa, bicornuate uteri, didelphic uteri, and even dense adhesions.

CT scanning or MRI: These imaging studies are not usually needed unless the findings on sonohysterography or
hysterosalpingography are inconclusive. MRI is a useful modality for examining the uterine fundus when distinguishing
between a septate and bicornuate uterus.

Diagnostic Procedures
Endometrial biopsy is indicated in perimenopausal/menopausal women and in women older than 35 years with irregular bleeding
(eg, heavy menses, irregular spotting, prolonged menses) and in women with absent menses with at least 6 months of
unopposed estrogen. It should be considered for women younger than 35 years who are suspected to have anovulatory bleeding,
do not respond to medical therapy, or have prolonged unopposed estrogen exposure and for adolescent women with >2 year
history of anovulatory bleeding, especially with risk factors (ie, obesity). In these women, the risk for endometrial hyperplasia or
cancer is increased.

In any woman undergoing endometrial ablation, benign endometrial tissue should be pathologically confirmed.

Treatment

Preoperative Details
Appropriate surgical management always begins with accurate history taking, physical examination, and careful workup of the
suspected problem. In preparation for hysteroscopic procedures, the following considerations may be useful.

Antibiotic prophylaxis

For hysteroscopy, prophylactic antibiotics are not indicated unless the patient has clinically significant valvular disease or a history
of tubal occlusion due to pelvic inflammatory disease.

Cervical stenosis

In patients with known cervical stenosis or tortuous cervical canals, preoperative vaginal or oral misoprostol, or intraoperative
vasopressin 1% administered paracervically may be used to assist in cervical dilation. Additionally, when intravaginal misoprostol
is used for preoperative cervical ripening in the premenopausal women (without known cervical stenosis), it has been described to
increase the ease of dilation, reduce the need for mechanical cervical dilation, and lower the rate of cervical laceration.[69, 70]
However, not all studies have shown the same improvement.[71] The potential benefits still need further evaluation in the
postmenopausal population and potential side effects (vaginal bleeding, cramping, fever, diarrhea, and nausea) must be
considered for all women. The optimal dose and route of administration (vaginal or oral) remains an area of investigation.

A randomized, double-blind, placebo-controlled trial by Nakano et al that included 158 postmenopausal women who received 200 
µg of misoprostol or placebo before diagnostic hysteroscopy reported no significant differences between groups in pain intensity
and duration of hysteroscopy and also that additional cervical dilatation was needed in 11 women in the misoprostol group versus
9 in the placebo group.[72]

Endometrial preparation for ablation

Before ablation procedures are performed, the administration of a GnRH agonist in the luteal phase of the previous menstrual
cycle in ovulating women improves visibility and provides a smooth, pale, hypovascular surface 3-4 weeks later (after the patient
has her menses). These changes make the procedure easier to perform and improve its success rate.

For those who do not want a GnRH agonist, the simultaneous use of a GnRH antagonist with progesterone at any point in the
menstrual cycle theoretically creates a similar surface after the patient has her menses, but it has fewer adverse effects and
allows greater scheduling flexibility than does the other method.

One antagonist, ganirelix acetate (Antagon) (Organon, Inc, Oss, the Netherlands), is available packaged with gonadotropins for
use in infertility therapy. However, cetrorelix, (Cetrotide; Serono, Inc, Rockland, Mass) is available packaged alone. This author
has successfully used a single 3-mg dose of cetrorelix administered subcutaneously every 4 days along with
medroxyprogesterone acetate (Provera) 10 mg taken orally for 5 days. Unlike the agonist, the action of the antagonist is
immediate, suppressing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) without any of the flare effect commonly
observed with the agonist. The ablation procedure is then typically performed after the patient completes her menses, which
usually begins 2-3 days after she takes the last progesterone tablet.

Finally, suction curettage done before ablation creates a comparable surface. However, it appears to be most effective in the late
luteal phase or during menstruation, when the endometrium is loosely attached. In this author's experience, the medical
approaches are superior.

Fibroids

For large submucosal fibroids, the use of a GnRH agonist decreases uterine volume by approximately 30%. It may decrease
blood loss and allow for an easier and more complete resection, though some data suggest that the change in tissue quality may
make the procedure technically more difficult than before, negating other benefits. There is currently no consensus on their use
prior to hysteroscopic myomectomy.[37] Benefits of preoperative use should be weighed against their cost and side effect profile.
[53]

Large uterus
During ultrasonography or sonohysterogram, measurements of the uterine dimensions are helpful. In particular, a uterus longer
than 10 cm makes the case difficult because of the length of the hysteroscope (typically 35 cm) because it must traverse the
length of the uterus, cervix, and vagina while maintaining a position outside the introitus with enough distance to attach the
camera and manipulate the fluid inflow-outflow valves and the surgical instruments. Also, maintaining intrauterine pressures with
large cavities is more difficult than with small cavities.

Intraoperative Details
Anesthesia

The type of anesthesia used depends on the procedure, the patient's level of anxiety, and the anesthesiologist's expertise. Simple
diagnostic procedures can be completed without anesthesia, with a paracervical block alone, or with mild sedation. For extensive
procedures or for patients with a low pain tolerance, general or regional anesthesia is indicated. If electrosurgery is to be
performed, sufficient anesthesia must be given to ensure that the patient does not move with uterine stimulation because of the
risk of uterine perforation and intraperitoneal injury.

Positioning

The patient is placed in the dorsal lithotomy position then prepared and draped in a sterile manner. Unless a laparoscopy is also
planned, the patient's thighs should be positioned at a 90° angle to the pelvis to create enough space for the surgeon to
manipulate the hysteroscope. The patient's perineum should be just past the edge of the table, with the coccyx and sacrum well
supported on the flat surface of the table. The patient's legs should be secured in the leg stirrups to avoid any abrupt movements,
which can cause nerve or muscle injury to the patient or potential injury to the surgeon. The surgeon should be seated with the
operative field and hysteroscope at the level of his or her abdomen. If it is positioned higher, the surgeon's shoulders become
fatigued, and, if it is positioned lower, the instrument is hard to maneuver and is likely to become contaminated.

Hemostasis
Attempts to reduce blood loss and fluid deficits are reported (and ultimately tried by this author). Use of cold (ie, 5°C) distention
medium causes vasoconstriction and reduces blood loss and distention fluid deficits. However, the patient's core body
temperature substantially decreases and may interfere with the anesthesia process. Vasopressin in dilute solution (ie, 1%) can be
injected paracervically to help constrict the cervical and lower uterine branches of the uterine artery and its collaterals, reducing
blood loss and fluid deficits.

Placing the Hysteroscope

Bladder catheterization

At the discretion of the surgeon, the bladder may need to be emptied with a straight, red rubber catheter by using sterile
technique.

Examination under anesthesia

Bimanual examination should always be performed before the endocervix and uterus are dilated and entered. This examination
aids the surgeon in assessing angles and preventing perforation.

Cervical dilation

Using the standard approach, the cervix is manually dilated with metal dilators to the same diameter as the outer diameter of the
outer sheath of the hysteroscope setup. A single-tooth tenaculum is placed on the anterior lip of the cervix while dilating to help
straighten the cervix and uterus. Take care to avoid creating a false cervical passage that could make it difficult to continue with
the surgery. If the surgeon is unsure of the path of the cervical canal, lacrimal duct probes or flexible uterine sounds should be
used to determine the correct angle. Ultrasonographic guidance for dilation may be helpful in severe cases.

Visualization of the uterine cavity

After the cervix is dilated, the hysteroscope is inserted into the endocervical canal and advanced into the uterine cavity (with the
distention medium flowing) under direct visualization to limit the risk of perforation. The tenaculum on the cervix is left in place to
help in manipulating the uterus, and the vaginal speculum is removed to increase maneuverability of the hysteroscope. If the
cervix was dilated too much and if fluid is leaking extensively, a purse-string suture can be placed around the cervix using 0-Vicryl
to limit this leakage. The suture should be removed at the end of the procedure.

Alternatively, a vaginoscopic approach has also been defined.[73] Distention media is introduced into the vagina at the same
pressure used for dilation of the uterine cavity (around 30-40 mm) to distend the vaginal cavity. The hysteroscope is then used to
visualize the cervix and facilitate its entry into the cervical canal. The use of a speculum and tenaculum is not needed with this
approach.
Techniques

Procedures are individually described below with regard to the type and width of the hysteroscope, the type of medium, and the
use of surgical instrumentation and energy sources, depending on the indications and desired outcomes.

Diagnostic hysteroscopy

A small 5- or 7-mm hysteroscope can be used with isotonic sodium chloride distention medium. A 30° scope is preferable to
clearly visualize the tubal ostia. The ability to introduce small surgical instruments through an operating channel is optimal. Office
procedures can be performed with 2.5- to 3- mm flexible or rigid hysteroscopes that are attached to isotonic sodium chloride
solution in a bag or 30-mL syringe. Some models have a small operating channel through which a thin-wired biopsy forceps can
be placed. This channel is enough to sample suspected areas or to remove small polyps.

Diagnostic mini-hysteroscopy, using a 3.5 mm single-flow diagnostic sheath (ACMI Slim-Line Hysteroscope, Southborough,
Mass), has also proven to be an easy and reliable procedure with acceptable patient tolerance.[74]

Endometrial ablation

First-generation endometrial ablation using the roller-ball or roller-barrel method, resection method, and laser method are
described below.

The roller-ball or roller-barrel method

The cervix must typically be dilated to 7-9 mm depending on the resectoscope used. An Iglesias grip mechanism on
the resectoscope is preferred because it maintains the electrode within the shaft at rest. A 12° scope is suggested
because it provides a panoramic view of the uterine cavity. A coagulation mode of 50-100 watts is used.

A roller barrel improves the uniformity of contact with the endometrium compared with the roller ball, but it may
inadequately ablate the cornua and fundus. A 2-mm rollerball is more effective than a 4-mm ball because it has
more current density for a given power level. The ball or barrel is extended and allowed to passively return toward
the sheath at a rate of 1.0-1.5 mm/s. In clinical use, the proper amount of power is being used if the crater that is
formed is 25% of the volume of the electrode and if the borders of the crater are carbonized.

On occasion, the roller ball or barrel may become coated with tissue, and it may have to be removed and cleaned
with a sterile gauze. If the endometrium is not thinned, resection may be preferred. The uterine cornua and tubal
angles are ablated first because of their difficulty. Starting at the 9-o'clock position, the lateral and anterior walls are
ablated next because blood, debris, and bubbles rise, making later ablation attempts more difficult. The posterior
wall is then ablated by continuing in a clockwise fashion. Do not continue to ablate over areas that have already
been treated because of the risk of uterine perforation.

The resection method: As with the other procedures, the cervix is typically dilated to the size of the resectoscope. A
blended current of 70-100 watts is preferred. A 5- or 7-mm loop electrode is used and extended. The electrode is allowed
to return passively at 1.0- 1.5 mm/s. A methodical approach should be used, with a plan to uniformly continue around the
cavity. Do not resect the same place twice. The angles of the tubal ostia are difficult to ablate with the loop electrode, so a
small rollerball is preferable. Also, the corpus and isthmus may be thin; therefore, a rollerball is preferable in this area as
well. The correct wattage is being used if the loop easily penetrates the tissue without tearing it. Depending on the system
used, the strips of resected tissue may require removal intermittently with polyp forceps. All tissue is sent to the pathologist
for histologic evaluation.

The laser method

The neodymium-yttrium-aluminium-garnet laser (Nd:YAG laser) can also be used for ablation. Laser energy is
delivered to the tissues via a fiber inserted through an operating hysteroscope. The laser energy provides a tissue
penetration of 5-6 mm. Two techniques are commonly described. The dragging technique requires the laser fiber to
be in constant contact with the endometrium, which ultimately results in vaporization of the tissue.[75]

Alternatively, coagulation can be induced with the blanching technique in which the fiber does not come in direct
contact with the endometrium.[76] Both techniques require constant motion to minimize risk of perforation. Choice of
distention media includes normal saline or Dextran 70.

Second-generation endometrial ablation, hydrothermal method

The HydroThermAblator System (Boston Scientific, Natick, Mass) is the only second generation ablation device that uses direct
visualization with the hysteroscope. A single-use 3 mm hysteroscope coated with polycarbonate is inserted into the endometrial
cavity. Saline is instilled at low intrauterine pressures of < 45 mm Hg and then heated to 90°C. This low pressure is used to
prevent flow of heated saline through the fallopian tubes. After the treatment is complete, cool saline is used to replace the heated
saline prior to removal of the device from the cavity. Endomyometrial necrosis to a depth of 2-4 mm is achieved after 10 minutes
of treatment. The endometrial cavity is uniformly ablated with this method, including both cornua.[77]

Submucosal fibroids

Several instruments may be used for hysteroscopic myomectomy. They include the resectoscope (by far the most common),
scissors, the laser, and the morcellator. Some gynecologists inject vasopressin into the cervical stroma before the procedure to
decrease blood loss and surgical time.[68]

Resection

This is similar to resection of the endometrium, but the resectoscopic method results in resection of only the fibroid
rather than the surface layer of endometrium. Take care when resecting a fibroid to limit the resection to only the
fibroid without resecting the adjoining endometrial tissue, especially in women desiring to conceive. The fibroid can
be resected to the level of only the endometrium. After some is removed, any remaining intramural portion of the
fibroid may begin to invert into the endometrial cavity. Surgeons should apply their skill and experience to estimate
how many passes they will continue to resect while aiming to avoid uterine perforation. The loop can often be used
to separate the fibroid from the pseudocapsule, often called cold-loop resection, facilitating its removal and helping
to identify normal myometrium and endometrium to avoid coagulation, especially in young women desiring to
conceive.

For resection of a submucosal fibroid, high cutting power is required. Using the cutting mode at 80-100 watts
provides clean cuts through the fibroid and facilitates a rapid technique. Power settings lower than this do not allow
for easy resection and only delay completion of the procedure, with resulting fluid deficits.

Resectoscopes historically relied on monopolar currents to cut tissue and thus required the use of hypotonic
electrolyte-free distention media. Strict fluid monitoring is an obvious need. Fortunately, bipolar resectoscopes are
now in use. The Princess resectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, Ill) is a 7-mm
resectoscope — the smallest bipolar resectoscope currently available.

Obstructed visualization due to floating tissue fragments during resection can prove difficult and may necessitate
catching the loose tissue with the loop electrode or poly forcep, removing the hysteroscope to grab the tissue,
followed by reintroduction of the scope. To address this problem, the Bipolar Chip E-Vac System (Richard Wolf
Medical Instruments Corporation, Vernon Hills, Ill) has been introduced to the market. The system uses a traditional
resectoscope with an automatic chip aspirator and can be used with monopolar or bipolar current. A microprocessor
controlled pump pulses at an adjustable level to aspirate chips out through an operative channel in the
hysteroscope while preventing fluid losses and uterine collapse. Published reviews favorably evaluate this new
system but do note that the aspiration system is prone to becoming clogged if tissue chips are too large.[78] This
system encourages the surgeon to remove smaller tissue fragments with each pass of the resectoscope.

Vaporization

Vaporization of a fibroid can also be performed through the use of a variety of different shaped electrodes. The
chosen electrode is dragged along the surface of the myoma to directly vaporize the tissue. Perforation from
prolonged use at one point can occur. Using this method, tissue is destroyed and thus unavailable for pathologic
examination.

The Gynecare Versapoint Bipolar Electrosurgery System (Johnson & Johnson Gateway LLC, Piscataway, NJ)
provides the opportunity to use both a vaporizing electrode and resecting loop electrode with normal saline
distention media for a variety of operative needs. Vaporizing electrode options include a ball or spring electrode for
rapid vaporization and desiccation and a twizzle electrode for more precision.

Laser ablation: Fibroids less than 2 cm in diameter can also be ablated with the use of the Nd:YAG laser. The laser fiber is
dragged over the surface of the fibroid until it is flat. As with its use for endometrial ablation, continual movement is
required and tissue is destroyed and not available for pathology evaluation.

Morcellation

Hysteroscopic morcellation may also be used for resection of submucosal fibroids, as well as, endometrial polyps.
The Intra Uterine Morcellator (IUM) (prototype: Smith & Nephew Operative Hysteroscopy System, Andover, Mass)
provides a nonelectrosurgical removal option. The morcellator consists of an inner rotating or reciprocating tube
electronically controlled by a foot pedal and a 4.5-mm outer tube. Only a single insertion through a 9-mm rigid
hysteroscope is required, followed by saline inflation of the uterus. After the fibroid or polyp is visualized, the
morcellator is placed against the lesion and rotation (optimal for polyp morcellation) or reciprocation (optimal for
myomas) of the inner tube cuts the lesion as controlled suction is used for continuous tissue removal and outflow.
Each tube has an opening at the end of it for visualization of cutting.

Advantages of morcellation include the use of physiologic saline for distention and irrigation and the availability of
tissue fragments for histologic analysis after morcellation. Of note, the system is not designed to be used for
submucosal fibroids with greater than 50% intramural penetration. Mean operating time has been demonstrated to
be shorter when compared to resectoscopy in both a retrospective comparison and a randomized controlled pilot
study among residents in training.[79, 80] The latter study demonstrated a significantly reduced operating time of
more than 8 minutes in comparison to conventional resectoscopy when using the IUM for polyps as well as type 0
and small (< 30 mm) type 1 submucosal myomas (17 min vs 30.9 min).

Interlace Medical, Inc (Framingham, Mass) has also developed a hysteroscopic morcellation system not yet
commercially available. The system is used with normal saline and is being tested using 2 lens options. The rigid
rod lens hysteroscope has an overall outer diameter of approximately 6.2 mm and the flexible hysteroscope has an
overall diameter of < 5.5 mm. The morcellator is designed to both reciprocate and rotate simultaneously. The metal
and coating used make this device sharp and decreases tissue clogging. There is a side window in the rod for
 visualization of cutting. The morcellator is designed to treat type 0 and type 1 submucosal fibroids and has been
used successfully during user preference testing for fibroids as large as 5 cm (oral communication). In addition to
successful testing under general anesthesia, procedures using this device are also reported to be acceptable to
sedated patients with use of a paracervical block. The system has the potential to beperformed in the office.

Fibroids with an intramural component

In general, nonhysteroscopic myomectomy should be considered for fibroids with greater than 50% myometrial extension (type II,
G2 fibroids), which are technically the most difficult resections to perform through the hysteroscope. In addition, resection of the
intramural component is associated with the greatest risk of fluid intravasation and decreases the chance per procedure of
achieving complete resection.[54] However, different techniques for hysteroscopic resection have been proposed for the
experienced surgeon. Resection of a completely intramural fibroid poses the risk of intravasation of media due to prolonged
procedure time.[39]

Resection

After initial excision of the intracavitary portion of the fibroid, the intramural component will typically expel into the
cavity, but the volume of the remaining intramural fibroid will subsequently increase. Thus, excising only the
intracavity portion can prove futile.

One surgical option is complete electrosurgical excision of the fibroid, including the intramural component. This
technique is associated with increased risk of perforation, bleeding, thermal damage, and fluid absorption.

Another suggested resection technique involves using a resectoscope to cut the capsule of the myoma away from
myometrium to prevent the fibroid from sinking into the muscular layer, followed by grasping of the myoma with
graspers. Rotation can then be used to pull the myoma into the intrauterine cavity.[81] This is accomplished under
ultrasonographic guidance. Supporting data is limited, with only 2 cases reported using this technique.

Cold loop: Alternatively, the cold loop myomectomy has been proposed.[38] The surgeon first excises the intracavitary
portion of the fibroid and then uses a loop, not connected to an electrical source, for blunt dissection. The loop is used to
mechanically create a plane between the fibroid and myometrium. Once the fibroid is detached from the myometrium, it
can then be removed in pieces.

Toto enucleation: Alternatively, in toto enucleation has been proposed.[82] An elliptic incision is made in the endometrial
mucosa covering the fibroid until the cleavage zone of the myoma and myometrium is reached. Tissue bridges between
the myoma and muscle fibers are resected with electrocautery, resulting in protrusion of the fibroid into the uterine cavity.
Myomectomy can then be completed by slicing. This technique has been successful in a small series of women (41 of 44)
with myomas less than 4 cm in diameter with a reported mean operating time of 27 minutes.[82]

Uterine contractions: Induction of uterine contractions by facilitating rapid changes in intrauterine pressure, uterine
massage, or pharmacologic agents has also been proposed as a means to encourage migration of the residual intramural
fibroid into the uterine cavity.

Intrauterine adhesions

The standard treatment of intrauterine adhesions is hysteroscopic resection. The operative hysteroscope is introduced into the
uterine cavity and centrally located synechiae are lysed first. Progression is then made to the margins of the cavity. Thin, filmy
adhesions can often be lysed with blunt dissection, but thicker adhesions require excision or transection. This can be
accomplished with scissors, vaporization with bipolar electrocautery, or fiberoptic laser. Concurrent use of laparoscopy or
ultrasonography may be useful with extensive adhesive disease to reduce the risk of perforation.

Intraoperative fluoroscopic guidance during synechiolysis has also been proposed.[45, 83] With this technique, a 16-gauge, 80-
mm needle or an 18-gauge, 100-mm needle is used to introduce contrast transcervically along side the hysteroscope. As contrast
is injected, pockets of endometrium are identified and the needle is used to create a passageway in the surrounding adhesions.
Subsequent sharp resection with the needle or hysteroscopic scissors then follows. Advantages of this technique may include
early detection of false passage and capability to concurrently assess tubal patency.[83]

Mechanical disruption of mild intrauterine adhesions through the use of pressure lavage under ultrasonographic guidance has
also been proposed.[84]

Transection and resection of the uterine septum

Three methods for performing this procedure are discussed. A 12° scope is preferred with this procedure. If extensive lysis is
indicated, laparoscopy can be used as an aid to decrease the risk of perforation by visualizing the illuminated cavity intra-
abdominally.[14]

The first method involves the use of resectoscope, a straight, 5-mm-loop electrode, and a blended current of 70-100 watts. The
septum is transected until small areas of bleeding are observed; these indicate that myometrium is reached. Do not allow the
intrauterine fluid pressure to become higher than the patient's mean arterial pressure because this may prevent these bleeders
from being observed easily.

In the second method, a 5- to 7-mm operative hysteroscope and small scissors are used to transect the septum until the
important, small bleeding areas are observed. The intrauterine pressure helps in expanding the septum as it is cut.
With the third method, an operative hysteroscope and vaporizing electrode (ie, VersaPoint system) is used with 0.9% sodium
chloride solution. By vaporizing the septum distally toward the fundus, it is completely removed rather than just transected.

Resection of uterine septum can be performed with scissors, a laser, or the resectoscope. When the septum is narrower than 3
cm at the fundus, incising it from distal to cephalic may allow the fibroelastic band to retract; this usually results in minimal
bleeding. A broad septum requires a different approach. The first step is a lateral, alternating technique of side-to-side resection
up to 0.5 cm from the fundus. Then, the remainder is removed from cornua to cornua to avoid damage to this area and to
decrease bleeding. Laparoscopy or transabdominal ultrasonography may be useful to evaluate the external uterus during
resection. If ultrasonography is used, the bladder should be left full to best visualize the uterus.

Although the septum is usually contained within the uterine cavity, a cervical septum may be present. The cervical septum can be
incised with the use of Metzenbaum scissors followed by hysteroscopic resection of the corporal portion. Historically, removal has
not been recommended as it may result in bleeding and cervical incompetence.[14] However, recent studies have demonstrated
improved outcomes after resection. Decreased operating times (36 min vs 73 min), use of less distending media and favorable
reproductive outcomes have been reported with resection when compared to retention of the cervical septum.[85]

Transcervical tubal sterilization

With the Essure system, a 5-mm hysteroscope is used to introduce a delivery catheter that contains a 3.85 cm flexible coil called
a microinsert into the proximal portion of the fallopian tube. The inserts are made of a stainless steel inner coil wound in
polyethylene fibers and an outer coil of nickel titanium. After a microinsert is placed at the uterotubal junction, the delivery catheter
is removed and the outer coil of the insert expands. Three to eight trailing coils of the insert should remain visible at the tubal
ostia. The inner polyethylene fibers induce tissue in-growth into the insert, facilitating occlusion of the tubal lumen by 12 weeks.
The procedure can be performed without any anesthesia with acceptable pain scores.[82] Additionally, it can be performed safely
and efficiently in the office setting with great overall patient satisfaction.[60, 86] Placement in the operating room may not offer any
advantage.[60]

IUD removal

By using a 5- to 7-mm hysteroscope and a 12° scope, the IUD is grasped with a toothed grasper. The IUD is pulled toward the
hysteroscope sheath. Pulling the IUD through the operating channel of the hysteroscope is impossible. Instead, the grasper is
held closed, and both hysteroscope and the IUD are pulled out together.

Proximal tubal cannulation

A 5- to 7-mm hysteroscope is used with a 30° scope. The occluded tubal ostia is cannulated approximately 1-2 cm with a flexible
tubal catheter, and indigo carmine is injected through the cannula and observed for its spillage through the fimbriated end by the
surgical assistant performing laparoscopy. If no patency is documented, the assistant straightens the fallopian tube as the
hysteroscopic surgeon slides a guide wire with a soft, flexible tip through the initial catheter and into the isthmic area of the
fallopian tube. The wire is then withdrawn and patency is evaluated again.

Operative office hysteroscopy

Small, more sophisticated instruments and improved flow systems now allow an operative therapy to be performed at the same
time as initial diagnosis. Procedures performed in the office setting include targeted endometrial biopsy, polypectomy,
myomectomy, adhesiolysis, metroplasty, and tubal sterilization.

The 5-mm Office Continuous Flow Operative Bettocchi Hysteroscope (Karl Storz, Tuttlingen, Germany) has encountered success
in the office setting.[87] This system includes a 2.9-mm rod lens system with an outer diameter of 5-mm. The instrument has a
sheath for irrigation and another for suction as well as a 5 F (1.6-mm) operative canal. An oval-shaped tip facilitates introduction
of the scope through a similarly shaped internal cervical os. Rotation of the scope by 90 degrees during entry to align the main
axis of the scope with the transverse axis of the internal cervical os is recommended. A 4-mm system with a 2-mm rod lens
system is also available. A number of 5 F instruments and bipolar electrodes are available for use with either system.

A variety of procedures have been well tolerated, without any analgesia or anesthesia, when using this system with a
vaginoscopic entry approach. Procedures include mechanical treatment of cervical and endometrial polyps, IUAs, and cervical
anatomical impediments, as well as Versapoint treatment of endometrial polyps and submucosal and partially intramural myomas.
[87, 73]

Small diameter miniresectoscopes are also available. Recently, a small, prospective, observational study using a prototype of the
5.3-mm monopolar resectoscope (Karl Storz, Tuttlingen, Germany) reported favorable results for the removal of endometrial
polyps and small (< 3 cm) type 0 or 1 submucosal fibroids.[88]

Postoperative Details
General posthysteroscopy care
Patients typically report cramping after the procedure. A single dose of ketorolac tromethamine (Toradol) reduces postoperative
discomfort. Opioid derivatives can be added, if needed, for severe pain. Peritoneal discomfort may occur if a substantial amount
of the distention media entered the abdominal cavity by way of the fallopian tubes. This discomfort generally subsides within 24
hours.

Most patients can go home within 1-2 hours. They require nonsteroidal anti-inflammatory drugs (NSAIDs) for 24-48 hours.
Patients may have some light-to-heavy spotting for a few days to a couple of weeks, depending on the procedure performed.

Intrauterine adhesiolysis

Prevention of postoperative adhesion formation begins with minimizing endometrial and myometrial trauma during the initial
hysteroscopic procedure. Postoperative stenting to prevent repeat adhesion formation with a silicone stent or an IUD has been
suggested, but copper IUDs may induce an excessive inflammatory reaction and the Progestasert IUD (Alza Pharmaceuticals,
Vacaville, Calif [discontinued in 2001]) may be too small to achieve adequate results.[14] There is currently no data on the
potential use of the levonorgestrel-releasing intrauterine device (Mirena), but a similar size concern remains.

Cook Women's Health (Spencer, Ind) makes a triangular balloon catheter that may improve separation of the uterine walls at the
cornua during the healing phase (personal communication).

A Foley catheter placed into the uterine cavity with estrogen supplementation (conjugated estrogen 5 mg for 25 d with
medroxyprogesterone 10 mg for the last 5 d) also has been used for stenting the cavity.[22] The purpose of the estrogen is to limit
the amount of postoperative bleeding due to vasoconstriction of small blood vessels and to rapidly rejuvenate the endometrial
lining, which is less prone to form adhesions than a persistently raw, cut surface. If any sort of intrauterine stent is used, antibiotic
prophylaxis should be considered for the duration of the stent placement.[14] Oral doxycycline 100 mg twice daily is typically
used.

The use of nonsteroidal medications helps with uterine cramping and reduces adhesion formation in other pelvic procedures.
Follow-up hysterosalpingography or diagnostic hysteroscopy after withdrawal bleeding is recommended. Some authors report
normal findings on 90% of follow-up hysterosalpingography studies.[14] Additionally, an early second-look hysteroscopy (2-4
weeks postoperatively) may facilitate treatment of new adhesions at an earlier, more amendable stage.[89]

Intrauterine use of auto-cross linked hyaluronic acid gel has also been examined in prevention of intrauterine adhesions after
hysteroscopic surgery. Administration of 10 mL of gel after adhesiolysis or hysteroscopic surgery for intrauterine lesions may be
associated with a significant reduction in the development and severity of de-novo adhesions.[90, 91] Long-term reproductive
outcomes are not yet available.

Resection of fibroids

If a fibroid resection is performed, inform the patient that she may pass small pieces of tissue, which may cause cramping.
Removal of extensive adhesions or fibroids raises the possibility of adhesion formation in the uterine cavity. Many surgeons
advocate the use of high-dose estrogen to encourage endometrial growth over any denuded areas. Conjugated estrogen 2.5-5
mg daily or estradiol 2 mg twice daily for 25 days, followed by progesterone for 5 days is typically sufficient.

To prevent the juxtaposition of the inner uterine walls during the initial phase of the healing process, placement of an intrauterine
catheter is recommended. Many types have been used, including the Malecot and Foley catheters. The author prefers to use a
pediatric Foley catheter with the balloon filled with 15-20 mL of sterile water because it has the added benefit of providing
tamponade to any areas that may be bleeding. The exterior end of the catheter is capped, and the patient is given doxycycline
100 mg twice daily until the catheter is removed 7 days later. The patient is instructed on how to remove the catheter (ie, cut the
catheter with scissors and pull it out).

One area of uncertainty pertains to hysteroscopic resection of large submucosal fibroids, especially those with extensive
myometrial involvement. When fibroids are removed through a laparotomy and a large defect is repaired, the patient is counseled
not to labor when she is pregnant. Vaginal birth is generally, but not universally, an accepted means of delivery after hysteroscopic
resection of type 0 or 1 fibroids.[53] However, further consideration may be given if the surgery resulted in large defects or if it was
complicated by uterine perforation. Intuition suggests that patients who have large defects after a hysteroscopic procedure should
be counseled similarly.

Follow-up
Follow-up in 2-4 weeks is recommended to evaluate the patient and to probe the cervix (when ablation was performed) to break
up any scar tissue that may have developed near the internal os. For simple diagnostic hysteroscopy, no postoperative visit is
usually necessary.

After resection of fibroids or polyps or transection of a septum, sonohysterography should be performed to confirm a normal
uterine cavity. If adhesions were removed, diagnostic hysteroscopy in the office or operating room is likely to be most sensitive.

Follow-up HSG 3 months after placement of Essure microinserts is required to confirm proper placement and tubal occlusion. A
review of 50,000 hysteroscopic Essure sterilizations identified 64 reported pregnancies. Most pregnancies, 47%, occurred in
patients without appropriate follow-up. Other notable causes included misinterpretation of HSG and preprocedural pregnancy.[66]
The physician must place emphasis on patient education and stress importance on follow-up imaging as well as additional
contraception use until confirmation of occlusion is documented.

For excellent patient education resources, visit eMedicineHealth's Pregnancy Center and Women's Health Center. Also, see
eMedicineHealth's patient education articles Miscarriage, Vaginal Bleeding, Amenorrhea, Uterine Fibroids, and Female Sexual
Problems.

Complications
The most common complications after hysteroscopy are bleeding and uterine trauma. An accepted rate for all complications
during surgical hysteroscopy is 3.8%.

Mechanical complications

Perforation and cervical trauma are 2 of the most common complications of hysteroscopy, with uterine perforation rates of
approximately 0.7-0.8%.[9] Risk factors for perforation include cervical stenosis, severe uterine anteflexion or retroflexion,
infection, myomas of lower uterine segments, and synechiae.[92] Most cervical traumas and uterine perforations occur during
dilation of the cervix.

Cervical lacerations can occur from tearing of the single-toothed tenaculum from the cervix. Some authors suggest using a
relatively atraumatic instrument, such as a double-toothed tenaculum or a ringed forceps, to prevent this complication. Using
medical or mechanical preoperative cervical dilators may help to decrease resistance during dilation. In addition, ultrasonographic
guidance may help to direct dilating maneuvers. Use of the small-diameter and flexible hysteroscopes can ultimately limit the
need for excessive dilation and thereby limit one of the most dangerous portions of the procedure. The vaginoscopic entry
approach, when appropriate, eliminates the need for a tenaculum entirely.

Uterine perforations can occur during operative maneuvers as well. Care should be taken during procedures in the cornua
because this is the thinnest portion of the myometrium. In general, a small midline or fundal injury with a blunt instrument does not
have clinically significant sequelae if bleeding is minimal, but large rents or those caused by sharp or electrosurgical instruments
may result in a need for diagnostic laparoscopy to completely evaluate the patient for bleeding or visceral injury. Lateral
perforations involve risk of injury to vessels and should be further inspected with diagnostic laparoscopy or interventional
radiology and/or angiography.

Whenever electrical or laser injury to the bowel or bladder is suspected, laparoscopy or laparotomy is required for complete
evaluation. The risk of peritonitis, sepsis, and death are most often associated with unrecognized and untreated thermal injuries to
the viscera. Some of these thermal visceral injuries occur without apparent perforation of the uterus. For procedures in which
electrical or laser energy is used, the surgical tip should be kept in direct view to avoid thermal injury.

Although rare, cases of tubal perforation following Essure microinsert placement have been reported.

Media-related complications

The risk of gas embolism is the primary complication associated with the use of CO2 as the distention medium. Because of its
solubility in plasma, CO2 has a wide margin of safety. Trendelenburg positioning, cervical trauma, and overdilation of the cervix
should be avoided to help prevent embolus formation. Intrauterine pressures should be maintained below 100 mm Hg, with
maximal flow rates less than 100 mL/min.[93]

When gas embolism occurs, results can be devastating, and circulatory collapse can occur. If an embolus is suspected because
of a change in a patient's vital signs (eg, hypotension, tachycardia, tachypnea, desaturation, decreased end-tidal CO2 value), the
hysteroscope should be removed, the patient positioned on her left side, and an IV bolus of isotonic sodium chloride solution
should be delivered as a first-line treatment. In addition, attempted percutaneous aspiration of an embolus is reported.[8] Further
evaluation with echocardiography and possible cardiopulmonary resuscitation may be indicated.

The risk of absorption of media is minimal under normal operative conditions. Risk factors for clinically significant intravasation of
fluid include prolonged operative procedures, the use of large volumes of low-viscosity media, or the resection of fibroids or
myometrial trauma that results in open uterine venous channels or unidentified perforations.[9] Intravasation can occur when the
intrauterine pressure is greater than the patient's mean arterial pressure.[93]

Fluid overload is rare with electrolyte-containing fluids. When excessive intravasation occurs, isotonic fluid overload occurs. This
is relatively easy to treat. However, these fluids are uncommonly used in operative procedures.

On the contrary, nonelectrolyte, hypotonic media, which are nonconductive, are most often used for the prolonged, complicated
electrosurgical procedures. These media have relatively serious adverse effect profiles (see Media above). When large volumes
of these solutions are absorbed, subsequent hyponatremia, hypervolemia, hypotension, pulmonary edema, cerebral edema, and
cardiovascular collapse can occur. Absorption (or deficit) of nonelectrolyte solutions must be closely monitored throughout
operative hysteroscopy.
For every liter of hypotonic media absorbed, the patient's serum sodium decreases by 10 mEq/L. If the patient's sodium level is
less than 120 mEq/L, she is at increased risk for having devastating complications. Hyponatremia can occur rapidly, resulting in
generalized cerebral edema, seizures, and even death. In general, if a fluid deficit is greater than 1500 mL or if the sodium level is
less than 125 mEq/L, the procedure should be terminated. Some suggest that of all nonelectrolyte media, 5% mannitol has the
safest adverse-effect profile because it can maintain a patient's osmolality despite hyponatremia, improving neurologic outcomes.
[8]

If the patient's sodium osmolality is less than 125 mOsm, forced diuresis with furosemide (Lasix) 40 mg IV, fluid restriction, and
administration of 3% sodium chloride at a rate to correct hyponatremia by 1.5-2.0 mOsm/L/h is required. To limit any cerebral
effects, do not correct the osmolality to more than 135 mOsm. Frequent assessments of the patient's sodium levels every 30
minutes may be appropriate to follow up this titration.

Dextran 70 can cause clinically significant overload in long surgical procedures; maximal absorption should not exceed 500 mL.
This type of overload does not respond to diuretic treatment because the kidneys poorly excrete Dextran 70. Therefore,
plasmapheresis may be required.[94, 8] Pulmonary edema and diffuse intravascular coagulation are other adverse effects
associated with the use of Dextran 70. The proposed mechanisms are fluid overload, toxic effects of Dextran 70 on the pulmonary
capillaries, and/or probable anticoagulant effects.[95, 92, 8]

Anaphylaxis is another complication of Dextran 70, with frequencies of 1 case per 1500-300,000 patients.[94, 95, 8] Treatment of
anaphylaxis includes diphenhydramine, epinephrine, steroids, and possible fluid and ventilatory support.

Bleeding
Bleeding during or after surgery is the second most common complication of hysteroscopy (0.25% of all cases). Myomectomy is
the procedure with the highest complication rate (2-3%).[8] Data suggest improvements in blood loss and preprocedural
hematocrit levels when patients are pretreated with GnRH agonists or oral contraceptives. Distention media themselves may yield
enough pressure to cause hemostasis during a procedure. In addition, the coagulating effects of surgical instruments can aid in
controlling bleeding during surgery.

If bleeding persists after surgery, a 30-mL Foley catheter balloon filled with 15-30 mL of fluid can be inserted into the cavity. This
balloon can easily be removed 24 hours later. Antibiotic prophylaxis should be given if a foreign body is placed in the uterus.
Vasopressin and misoprostol are alternate medications that can help with vasoconstriction and uterine contractions. As a last
resort, embolization of the uterine artery or hysterectomy is an option for definitive management.

Infection

Infection is an uncommon complication of hysteroscopy. Even with Dextran 70, which is a polymerized sucrose, infection is rare in
a patient who is preoperatively screened. If a patient has a preoperative infection or a significant history of pelvic inflammatory
disease, treatment before surgery is recommended, but prophylactic antibiotics do not reduce the risk of infection after surgery.
[92, 8, 19] If indicated, antibiotics should be used to prevent subacute bacterial endocarditis. Cystitis and endometritis are the
most common infections associated with hysteroscopic procedures, and these should be treated in a standard fashion.

Outcome and Prognosis

Outcomes for each type of procedure are discussed in Indications. Attempts at hysteroscopic evaluation or treatment are
obviously meant to overcome the traditional problems associated with invasive procedures performed in the past that involved
prolonged hospital stays, increased morbidity, and increased costs.

In addition to surgical success rates, other important considerations are the patient's long-term satisfaction, sexual function, and
overall quality of life. For example, when endometrial ablation is compared with hysterectomy, endometrial ablation is most cost-
effective, and patients undergoing endometrial ablation report 80-85% sexual, functional, and psychological satisfaction.

Future and Controversies

A variety of nonhysteroscopic instruments and techniques are now available for endometrial ablation. In general, these techniques
are safe, effective, quick, and easy to learn.

The thermal balloon used for menorrhagia has effects equal to those of hysteroscopic ablation, though amenorrhea is not as
common with the thermal balloon as with hysteroscopic ablation.[96] The balloon method is fast and simple to complete.

Cryoablation of the endometrium has also been used with success. The 3-dimensional bipolar ablation device NovaSure (Cytyc
Corporation, Mountain View, Calif) has been welcomed into the market. The procedure is performed to desiccate and coagulate
the endometrium and a superficial layer of myometrium by using radiofrequency energy delivered through a bipolar array.
Although the size of the instrument is a limiting factor, this technique is perhaps the easiest of all. The microwave endometrial
ablation system offers excellent rates of amenorrhea but requires increased dilatation of the cervix to introduce the mechanism.

Overall, these newer nonhysteroscopic techniques are associated with high patient satisfaction and achieve amenorrhea results
similar to hysteroscopic methods.[97]

An area of current interest is the feasibility and safety of simultaneous nonhysteroscopic endometrial ablation and Essure tubal
sterilization. Many women of reproductive age require ablation. Reproductive outcomes could be complicated should a women
become pregnant after an ablation. Thus, it would seem to be a reasonable option to offer permanent sterilization at the time of
endometrial ablation. Initial studies have indicated that combination therapy may safely be performed. Concomitant performance
of Essure sterilization and Thermachoice endometrial ablation has been shown to be feasible as a one-step approach and Essure
sterilization immediately following NovaSure global endometrial ablation has successfully been performed.[98, 99]

In addition to the innovative Essure sterilization system, a second hysteroscopic transcervical sterilization method is currently
seeking FDA approval. The Adiana (Hologic, Inc, Marlborough, Mass) sterilization method combines controlled thermal damage to
the endosalpinx and insertion of a nonabsorbable silicone elastomer matrix.

Innovative and borrowed techniques are enabling many other types of hysteroscopic interventions and new and improved
hysteroscopic designs. Instruments are becoming smaller than before, enabling additional in-office interventions.

As sonohysterography becomes common, as 3-dimensional sonographic software improves, and as physicians are required to
apply increasingly cost-effective procedures, these new technologies may be used to perform certain operative procedures that
now are performed with hysteroscopy. For example, MRI-guided ultrasonic destruction of fibroids has completed initial phase I
and II trials. The trials have shown the treatment to be highly acceptable to patients, safe, and effective at 24 months of follow-up.
[100] Patient demand for safe and minimally invasive treatments will continue to drive research and development.

Contributor Information and Disclosures

Author

John C Petrozza, MD Instructor, Department of Obstetrics and Gynecology, Harvard Medical School; Consulting Staff and Chief,
Division of Reproductive Medicine and IVF, Vincent Memorial Obstetrics and Gynecology, Director, MGH Fertility Center,
Massachusetts General Hospital

John C Petrozza, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Medical Association, American Society for Reproductive Medicine, Massachusetts Medical Society

Disclosure: Received stock options from Interlace Medical, Inc. for board membership.

Coauthor(s)

Jill A Attaman, MD Instructor in Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School; Fellow,
Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology Services, Massachusetts General Hospital

Jill A Attaman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Medical Association, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of
Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of
Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics
and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of
Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology
and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting;
Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group
Advisor for consulting; Received honoraria from ABOG for board membership.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Gretchen E H
Makai, MD and Emily Sikking, MD to the development and writing of this article.

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