Stepwise approach of hysteroscopic cytoreductive surgery for adenomyosis in patients with recurrent implantation failure

Objective: To study the value of hysteroscopic cytoreductive surgery for adenomyotic lesions to improve reproductive outcomes. We describe a feasible and novel minimal invasive stepwise approach, which did not result in postoperative adhesion formation and restored favorable reproductive outcomes. Design: Video article. Subjects: Patients aged <37 years, diagnosed with adenomyotic lesions by ultrasound and/or magnetic resonance imaging, who after a minimum of 6 months of medical treatment (gonadotrophin releasing hormone agonist or dienogest) failed to conceive with a minimum of two embryo transfer cycles of high-quality blastocysts were included. Exposure: The procedure was performed under conscious sedation, level 3b in an ambulatory surgical center. All patients received hormonal suppressive treatment (Dienogest 2 mgr per day or Triptoreline 3.75 mgr. IM once a month). Institutional Review Board approval and patient consent had been received for the study. The surgical steps included the following: center dot Identification of the inner myometrial lesion by combined ultrasonographic-hysteroscopic examination. center dot Incision of the lesion at the midline with a 15-Fr bipolar mini-resectoscope until the pathological adenomyotic tissue was totally removed. In contrast to ultrasound and magnetic resonance imaging, hysteroscopy can visualize a clear tissue structure difference between the adenomyotic fibrotic lesion and the surrounding healthy myometrium. Intermittent transvaginal ultrasound is mandatory to control the myometrial security zone, which should not be <1 cm. center dot Removal of the side wall pathological tissue, using the same hysteroscopic visual references, aiming to avoid thermal injury to the surrounding healthy myometrial layer. center dot Application of hyaluronic acid antiadhesive barrier gel under hysteroscopic vision. center dot Second-look hysteroscopy was scheduled after 8 weeks. Main Outcome Measure(s): Feasibility, reproductive outcomes, and complications (adhesions and placental disorders). Result(s): Fifteen patients underwent surgery and had histological confirmation of adenomyosis. Second-look hysteroscopy was possible in 13 of 15 women (2 spontaneous pregnancies) with reassuring postoperative results, showing only mild lateral wall adhesions in three cases. Pregnancy was registered in 12 women: one early miscarriage; seven ongoing pregnancies; and four deliveries of healthy infants with normal birth weight and no placenta-related complications. Conclusion: (s): In contrast to the current beliefs, mini hysteroscopy can identify and selectively resect adenomyotic lesions. The described technique in this video in our series of patients resulted in optimal postoperative healing and excellent reproductive outcomes. (c) 2024 by American Society for Reproductive Medicine.