Hysteroscopic Management of Intrauterine Disorders: Polypectomy, Myomectomy, Endometrial Ablation, Adhesiolysis, and Removal of Uterine Septum



Hysteroscopy is a minimally invasive and highly accurate means of diagnosing and treating a multitude of intrauterine pathology. It has become an indispensable tool for treating fibroids, polyps, synechiae, and congenital uterine anomalies and for performing endometrial ablation procedures. Specific classification systems exist for fibroids, synechiae, and congenital anomalies, which allow the pathology to be categorized into surgically meaningful groups that guide the approach for resection. Specific techniques are also required to treat each condition. The correct equipment must be used to ensure the optimal outcome, and the resection of these lesions should be carried out in a systematic manner. Clinicians should also be cognizant of complications they may encounter before performing these procedures so that greater care may be taken to avoid them.


Uterine Cavity Recurrent Pregnancy Loss Lower Uterine Segment Endometrial Ablation Uterine Perforation 
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  1. 1.
    Marlow JL. Media and delivery systems. Obstet Gynecol Clin North Am. 1995;22:409–22.PubMedGoogle Scholar
  2. 2.
    Corson SL, Brooks PG, Serden SP, Batzer FR, Gocial B. Effects of vasopressin administration during hysteroscopic surgery. J Reprod Med. 1994;39:419–23.PubMedGoogle Scholar
  3. 3.
    Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:347–66.PubMedCrossRefGoogle Scholar
  4. 4.
    Romer T, Lober R. Hysteroscopic correction of a complete septate uterus using a balloon technique. Hum Reprod. 1997;12:478–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Lurie S, Appelman Z, Katz Z. Curettage after midtrimester termination of pregnancy-is it necessary? J Reprod Med. 1991;36:786–8.PubMedGoogle Scholar
  6. 6.
    Marsh FA, Rogerson LJ, Duffy SR. A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy. BJOG. 2006;113:896–901.PubMedCrossRefGoogle Scholar
  7. 7.
    Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. BMJ. 2000;320:279–82.PubMedCrossRefGoogle Scholar
  8. 8.
    Bettocchi S, Selvaggi I. A vaginoscopic approach to reduce the pain of office hysteroscopy. J Am Assoc Gynecol Laparosc. 1997;4(2):255–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Nagele F, O’Connor H, Davies A, Badawy A, Mohamed H, Magos A. 2500 Outpatient diagnostic hysteroscopies. Obstet Gynecol. 1996;88:87–92.PubMedCrossRefGoogle Scholar
  10. 10.
    De Iaco P, Marabini A, Stefanetti M, Del Vecchio C, Bovicelli L. Acceptability and pain of outpatient hysteroscopy. J Am Assoc Gynecol Laparosc. 2000;7:71–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Davies A, Richardson RE, O’Conner H, Baskett TF, Nagele F, Magos AL. Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial. Fertil Steril. 1997;67:1019–23.PubMedCrossRefGoogle Scholar
  12. 12.
    Readman E, Maher PJ. Pain relief and outpatient hysteroscopy: a literature review. J Am Assoc Gynecol Laparosc. 2004;11:315–19.PubMedCrossRefGoogle Scholar
  13. 13.
    American College of Obstetricians and Gynecologists. Office based surgery procedures under sedation. Accessed 2 Jan 2013.
  14. 14.
    American College of Obstetricians and Gynecologists. Technology assessment no. 7: hysteroscopy. Obstet Gynecol. 2011;117:1486–91.CrossRefGoogle Scholar
  15. 15.
    Hulka JA, Peterson HA, Phillips JM, Surrey MW. Operative hysteroscopy: American Association of Gynecologic Laparoscopists’ 1993 membership survey. J Am Assoc Gynecol Laparosc. 1995;2:131–2.PubMedCrossRefGoogle Scholar
  16. 16.
    Valle R, Sciarra J. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment and reproductive outcome. Am J Obstet Gynecol. 1988;158:1459–70.PubMedGoogle Scholar
  17. 17.
    Hassiakos DK, Zourlas PA. Transcervical division of uterine septa. Obstet Gynecol Surv. 1990;45:165–73.PubMedCrossRefGoogle Scholar
  18. 18.
    Agostini A, Bretelle F, Ronda I, Roger V, Cravello L, Blanc B. Risk of vasovagal syndrome during outpatient hysteroscopy. J Am Assoc Gynecol Laparosc. 2004;11:245–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Cicinelli E, Schonauer LM, Barba B, Tartagni M, Luisi D, Di Naro E. Tolerability and cardiovascular complications of outpatient diagnostic minihysteroscopy compared with conventional hysteroscopy. J Am Assoc Gynecol Laparosc. 2003;10:399–402.PubMedCrossRefGoogle Scholar
  20. 20.
    Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol. 1983;147:869–72.PubMedGoogle Scholar
  21. 21.
    Serden SP, Brooks PG. Treatment of abnormal uterine bleeding with the gynecologic resectoscope. J Reprod Med. 1991;36:697.PubMedGoogle Scholar
  22. 22.
    Perez-Medina T, Bajo-Arenas J, Salazar F, Redondo T, Sanfrutos L, Alvarez P, et al. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: a prospective, randomized study. Hum Reprod. 2005;20(6):1632–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Martin-Ondarza C, Gil-Moreno A, Torres-Cuesta L, Garcia A, Eyzaguirre F, Diaz-Feijoo B, et al. Endometrial cancer in polyps: a clinical study of 27 cases. Eur J Gynaecol Oncol. 2005;26(1):55–8.PubMedGoogle Scholar
  24. 24.
    Al-Inany H. Intrauterine adhesions. An update. Acta Obstet Gynecol Scand. 2001;80:986–93.PubMedGoogle Scholar
  25. 25.
    March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol. 1978;130:653–7.PubMedGoogle Scholar
  26. 26.
    Emanuel MH, Verdel MJ, Wamsteker K. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol. 1995;172:547–52.PubMedCrossRefGoogle Scholar
  27. 27.
    Wortman M, Dagget A. Hysteroscopic myomectomy. J Am Assoc Gynecol Laparosc. 1995;3(1):39–46.PubMedCrossRefGoogle Scholar
  28. 28.
    Ergun A, Pabuccu R, Atay V, Kucuk T, Duru NK, Gungor S. Three sisters with septate uteri: another reference to bi-directional theory. Hum Reprod. 1997;12:140–2.PubMedCrossRefGoogle Scholar
  29. 29.
    Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS, Khapra A, Ross PL. The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 1996;88(5):761–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Stabinsky S, Einstein M, Breen J. Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding. Obstet Gynecol Surv. 1999;54(11):251–62.CrossRefGoogle Scholar
  31. 31.
    Asherman JG. Traumatic intrauterine adhesions. Br J Obstet Gynaecol. 1950;57:892–6.CrossRefGoogle Scholar
  32. 32.
    Netter AP, Musset R, Lambert A, Salomon Y. Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility and abortion. Am J Obstet Gynecol. 1956;71:368–75.PubMedGoogle Scholar
  33. 33.
    Dicker D, Ashkenazi J, Dekel A, Orvieto R, Feldberg D, Yeshaya A, et al. The value of hysteroscopic evaluation in patients with preclinical in-vitro fertilization abortions. Hum Reprod. 1996;11:730–1.PubMedCrossRefGoogle Scholar
  34. 34.
    Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan E, Burak F, et al. Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery. J Am Assoc Gynecol Laparosc. 2000;7:351–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Adoni A, Palti Z, Milwidsky A. The incidence of intrauterine adhesions following spontaneous abortions. Int J Fertil. 1982;27:117–78.PubMedGoogle Scholar
  36. 36.
    Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy-a prospective study. Hum Reprod. 1993;8:442–4.PubMedGoogle Scholar
  37. 37.
    Golan A, Schneider D, Avrech O. Hysteroscopic findings after missed abortion. Fertil Steril. 1992;58:508–10.PubMedGoogle Scholar
  38. 38.
    Romer T. Postabortion-hysteroscopy—a method for early diagnosis of congenital and acquired intrauterine causes of abortions. Eur J Obstet Gynecol Reprod Biol. 1994;57:171–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Westendorp ICD, Ankum WM, Mol BWJ, Vonk J. Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion. Hum Reprod. 1998;13:3347–50.PubMedCrossRefGoogle Scholar
  40. 40.
    Schenker JG. Etiology and therapeutic approach to synechia uteri. Eur J Obstet Gynecol Reprod Biol. 1996;65:109–13.PubMedCrossRefGoogle Scholar
  41. 41.
    The American Fertility Society. The American fertility society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies, and intrauterine adhesions. Fertil Steril. 1988;49:944–55.Google Scholar
  42. 42.
    Schenker JG, Margalioth EJ. Intrauterine adhesions. An updated appraisal. Fertil Steril. 1982;37:593–610.PubMedGoogle Scholar
  43. 43.
    Alborzi S, Dehbashi S, Khodaee R. Sonohysterosalpingographic screening for infertile patients. Int J Gynecol Obstet. 2003;82:57–62.CrossRefGoogle Scholar
  44. 44.
    Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictive value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility. Fertil Steril. 2000;73:412–17.PubMedCrossRefGoogle Scholar
  45. 45.
    Agostini A, Cravello L, Shojai R, Ronda I, Roger V, Blane B. Postoperative infection and surgical hysteroscopy. Fertil Steril. 2002;77:766–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Pabuccu R, Atay V, Orhon E, Urman B, Ergun A. Hysteroscopic treatment of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility. Fertil Steril. 1997;68:1141–3.PubMedCrossRefGoogle Scholar
  47. 47.
    Stephenson MD. Frequency of factors associated with habitual abortion in 197 couples. Fertil Steril. 1996;66:24–9.PubMedGoogle Scholar
  48. 48.
    Zikopoulos KA, Kolibianakis AM, Plateau P, de Munck L, Tournaye H, Devroey P, et al. Live delivery rates in sub fertile women with Asherman’s syndrome after hysteroscopic adhesiolysis using resectoscope or the versapoint system. RBM Online. 2004;8:720–25.PubMedGoogle Scholar
  49. 49.
    Ludmir J, Samuels P, Brooks S, Mennuti MT. Pregnancy outcome of patients with uncorrected uterine anomalies managed in a high risk-obstetric setting. Obstet Gynecol. 1990;75:906–10.PubMedGoogle Scholar
  50. 50.
    Siegler AM, Valle RF. Therapeutic hysteroscopic procedures. Fertil Steril. 1988;50:685–701.CrossRefGoogle Scholar
  51. 51.
    Verp MS, Simpson JL, Elias S, Carson SA, Sarto GE, Feingold M. Heritable aspects of uterine anomalies. I. Three familial aggregates with Mullerian fusion anomalies. Fertil Steril. 1983;40:80–6.PubMedGoogle Scholar
  52. 52.
    Harger JH, Archer DF, Marchese SG, Muracca-Clemens M, Garver KL. Etiology of recurrent pregnancy loss and outcome of subsequent pregnancies. Obstet Gynecol. 1983;62:574–81.PubMedGoogle Scholar
  53. 53.
    Acien P. Incidence of Mullerian defects in fertile and infertile women. Hum Reprod. 1997;12:1372–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Sparac V, Kupesic S, Ilijas M, Zodan T, Kurjak A. Histologic architecture and vascularization of hysteroscopically excised intrauterine septa. J Am Assoc Gynecol Laparosc. 2001;8:111–16.PubMedCrossRefGoogle Scholar
  55. 55.
    Fedele L, Dorta M, Brioschi D, Giudici MN, Candiani GB. Pregnancies in septate uteri: outcome in relation site of uterine implantation as determined by sonography. AJR Am J Roentgenol. 1989;152:781–4.PubMedCrossRefGoogle Scholar
  56. 56.
    Fedele L, Bianchi S, Marchini M, Franchi D, Tozzi L, Dorta M. Ultrastructural aspects of endometrium in infertile women with septate uterus. Fertil Steril. 1996;65:750–2.PubMedGoogle Scholar
  57. 57.
    Propst AM, Hill JA. Anatomic factors associated with recurrent pregnancy loss. Semin Reprod Med. 2000;18:341–50.PubMedCrossRefGoogle Scholar
  58. 58.
    Soares SR, dos Reis MMBB, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine diseases. Fertil Steril. 2000;73:406–11.PubMedCrossRefGoogle Scholar
  59. 59.
    Jurkovic D, Geipel A, Gruboeck K, Jauniaux E, Natucci M, Campbell S. Three-dimensional ultrasound for the assessment of uterine anatomy and detection of congenital anomalies: a comparison with hysterosalpingography and two-dimensional sonography. Ultrasound Obstet Gynecol. 1995;5(4):233–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Mintz M, Thickman D, Gussman D, Kressel H. MR evaluation of uterine anomalies. Am J Roentgenol. 1987;148:287–90.CrossRefGoogle Scholar
  61. 61.
    Pellerito JS, McCarthy SM, Doyle MB, Glickman MG, DeCherney AH. Relative accuracy of MRI imaging, endovaginal sonography, and hysterosalpingography. Radiology. 1992;183:795–800.PubMedGoogle Scholar
  62. 62.
    Takagi H, Matsunami K, Noda K, Furui T, Imai A. Magnetic ­resonance imaging in the evaluation of double uterus and associated urinary tract anomalies: a report of five cases. J Obstet Gynaecol. 2003;23:525–7.PubMedCrossRefGoogle Scholar
  63. 63.
    Doyle MB. Magnetic resonance imaging in Mullerian fusion defects. J Reprod Med. 1992;37:33–8.PubMedGoogle Scholar
  64. 64.
    Daly DC, Tohan N, Walters C, Riddick DH. Hysteroscopic resection of the uterine septum in the presence of a septate cervix. Fertil Steril. 1983;39:560–3.PubMedGoogle Scholar
  65. 65.
    Rock JA, Murphy AA, Cooper IV WH. Resectoscopic techniques for the lysis of a class V: complete uterine septum. Fertil Steril. 1987;48:495–6.PubMedGoogle Scholar
  66. 66.
    Assaf A, Serour G, Elkady A, El Agizy H. Endoscopic management of the intrauterine septum. Int J Gynaecol Obstet. 1990;32:43–51.PubMedCrossRefGoogle Scholar
  67. 67.
    Dabirashrafi H, Mohammad-Tabrizi M. Is estrogen necessary after hysteroscopic incision of the uterine septum? J Am Assoc Gynecol Laparosc. 1996;3:623–5.PubMedCrossRefGoogle Scholar
  68. 68.
    Jones HW, Jones GES. Double uterus as an etiological factor or repeated abortion, indication and surgical repair. Am J Obstet Gynecol. 1953;65:325–31.PubMedGoogle Scholar
  69. 69.
    March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. Am J Obstet Gynecol. 1987;156:834–42.PubMedGoogle Scholar
  70. 70.
    Chloe JK, Aggish MS. Hysteroscopic treatment of septate uterus with neodymium-YAG laser. Fertil Steril. 1992;57:81–4.Google Scholar
  71. 71.
    Hickok LR. Hysteroscopic treatment of the uterine septum: a clinician’s experience. Am J Obstet Gynecol. 2000;182(6):1414–20.PubMedCrossRefGoogle Scholar
  72. 72.
    Kupesic S. Clinical implications of sonographic detection of ­uterine anomalies for reproductive outcome. Ultrasound Obstet Gynecol. 2001;18:387–400.PubMedCrossRefGoogle Scholar
  73. 73.
    Fayez JA, Mutie G, Schneider PJ. The diagnostic value of hysterosalpingography and hysteroscopy in infertility investigation. Am J Obstet Gynecol. 1987;156:558–60.PubMedGoogle Scholar
  74. 74.
    Kirk EP, Chuong CJ, Coulam CB, Williams TJ. Pregnancy after metroplasty for uterine anomalies. Fertil Steril. 1993;59:1164–8.PubMedGoogle Scholar
  75. 75.
    Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril. 2000;73(1):1.PubMedCrossRefGoogle Scholar
  76. 76.
    Loffer FD. Complications of hysteroscopy-their cause, prevention, and correction. J Am Assoc Gynecol Laparosc. 1995;3(1):11–26.PubMedCrossRefGoogle Scholar
  77. 77.
    Ahmed N, Falcone T, Tulandi T, Houle G. Anaphylactic reaction because of intrauterine 32% dextran-70 instillation. Fertil Steril. 1991;55:1014–16.PubMedGoogle Scholar
  78. 78.
    Coccia ME, Becattini C, Bracco GL, Pampaloni F, Bargelli G, Scarselli G. Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesion. Fertil Steril. 2001;75:601–6.PubMedCrossRefGoogle Scholar
  79. 79.
    Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod. 2001;7:161–74.CrossRefGoogle Scholar
  80. 80.
    Kung RC, Vilos GA, Thomas B, Riddick DH. A new bipolar system for performing operative hysteroscopy in normal saline. J Am Assoc Gynecol Laparosc. 1999;6:331–6.PubMedCrossRefGoogle Scholar
  81. 81.
    Garry R, Hasham F, Kokri M, Mooney P. The effects of pressure on fluid absorption during endometrial ablation. J Gynecol Surg. 1992;8:10.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Minimally Invasive Gynecologic Surgery UnitNewton Wellesley HospitalNewtonUSA
  2. 2.Newton Wellesley Hospital, Harvard Medical SchoolNewtonUSA

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