Septum When recurrent pregnancy loss is associated with a single corpus containing a uterine septum, hysteroscopic division of the septum improves pregnancy outcome (the frequency of spontaneous abortion) at a rate comparable to abdominal metroplasty, with reduced morbidity and cost (see Chapter 33) (168–173). There are fewer data regarding infertility but there is some evidence that metroplasty does improve fecundity (174). Confirmation of the external architecture of the corpus is important and can be achieved using either MRI or three-dimensional ultrasound. One group described an office method of “see and treat” where dissection is continued until attaining two of three criteria (pain, bleeding, the visualization of myometrial fibers) to determine the end point of septal transection (175). This procedure can be successfully performed in the office setting using local anesthesia protocols, with additional 0.05% lidocaine with 1/200,000 epinephrine directly injected into the septum. The procedure may be performed mechanically with scissors or with energy-based techniques such as the Nd:YAG laser or an electrosurgical knife, needle, or loop. Because most septa have few vessels, scissors can be used to avoid the minimal risk for thermal damage.
Endometrial Polyps Endometrial polyps are frequently associated with abnormal uterine bleeding and infertility. Although such polyps can be removed with blind curettage, many are missed (157,159,162,163). Therefore, known or suspected endometrial polyps are treated more successfully with hysteroscopic guidance, which usually can be performed as an office procedure. Hysteroscopy may be used either to evaluate the result of blind curettage, to determine if the polyp is avulsed, or to direct the use of grasping forceps or small caliber scissors. Alternatively, for larger polyps, special polyp snares, electrosurgical needles, mechanical morcellators, or a uterine resectoscope may be used to sever the stalk or morcellate the lesion. For patients with infertility and endometrial polyps, it is not clear whether or not polyp number and size are related to outcome (176). Consequently, removal of all accessible polyps should be attempted if the process can be completed with minimal trauma.
Leiomyomas Hysteroscopy may be used to remove selected leiomyomas that involve the uterine cavity in women with heavy menstrual bleeding, infertility, or recurrent first trimester spontaneous pregnancy loss (155,177–183). This approach is limited based on the location, size, and number of the lesions. Preoperative administration of gonadotropin-releasing hormone (GnRH) agonists may help shrink submucous myomas, facilitating their complete removal, and more importantly, reduce operating time and systemic absorption of distension media (184–186).