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Objective: Immersion in water during labor and delivery has been studied as an alternative form of obstetric care. The aim of this study was to evaluate obstetrics and neonatal outcomes of women intending to use immersion in water for labor and delivery. Methods: This was a retrospective observational study conducted at a single center in Italy from January 2004 to January 2016. The clinical records of pregnant women intending to use immersion in water for labor and delivery were collected in a dedicated database and included in the study. Only the women who underwent immersion in water starting from the first stage of labor were included in the study. Inclusion criteria were women with uncomplicated singleton gestations and cephalic presentation at or later than 37 weeks of gestation, and with spontaneous onset of labor. The primary outcome of the study was the percentage of women who had both labor and delivery in water. Results: 389 women met the inclusion criteria and were included in the study. 256 (66%) were nulliparous, and 133 (34%) were multiparous. Out of the 389 women intending to use immersion in water for labor and delivery, 278 (71.5%) had labor and delivery in the water, 31 (8.0%) labor in water and delivery on land, and 80 (20.5%) had the first stage of labor in water, and the second stage and delivery on land. The incidence of perineal lacerations was 61.4%. Conclusion: The vast majority of the women who set out to labor and delivery in water achieve their aim.

Objective To evaluate the long-term reproductive outcomes in patients with dysmorphic uterus treated by hysteroscopic metroplasty with miniaturized instruments. Design Retrospective multicenter cohort study. Setting Tertiary care university hospitals. Patients The study was conducted on 214 women with a dysmorphic uterus (T-shaped, infantilis, or other type of dysmorphic uterus according to the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification system) with history of primary unexplained infertility (group 1) or repeated (>2) early miscarriages (group 2). Dysmorphic uteri were diagnosed by office hysteroscopy and 3-dimensional transvaginal ultrasound (3D-TVS). Interventions All patients underwent in office hysteroscopic metroplasty using a continuous-flow hysteroscope with a 5 Fr operating channel introduced into the uterine cavity using the vaginoscopic approach. Longitudinal incisions were performed on the fibromuscular constriction rings in the isthmic area and in some cases on the other uterine walls with a 5 Fr bipolar electrode or scissors. At the end of the procedure, an antiadhesive gel was applied into the uterine cavity to minimize adhesion formation. Postsurgical assessment of the uterine cavity was carried out through office hysteroscopy and 3D-TVS. All patients were followed for at least 24 months. Measurements and Main Results The metroplasty was completed in all cases, resulting in a significant increase of uterine cavity volume (100%) and optimization of uterine morphology in 211 of 214 women (98.6%). After 60 months, the overall clinical pregnancy rate was 72.9% (n = 156/214), and the live birth rate was 80.1% (n = 125/156). Specifically, 74 of 156 women (47.4%) conceived spontaneously (with a median time to pregnancy of 5.5 months), of whom 32.4% had previously failed 1 or more attempts at in vitro fertilization/intracytoplasmic sperm injection. Conclusion Our long-term follow-up data demonstrate that the hysteroscopic correction of dysmorphic uteri may result in a high live birth rate in women suffering from unexplained infertility or repeated miscarriages.

Study Objective To estimate the incidence of infection after diagnostic and operative hysteroscopic procedures performed in an in-office setting with different distension media (saline solution or CO2). Design Prospective, multicenter, observational study (Canadian Task Force classification II-2). Setting Tertiary women's health centers. Patients A total of 42,934 women who underwent hysteroscopy between 2015 and 2017. Interventions Of the 42,934 patients evaluated, 34,248 underwent a diagnostic intervention and 8686 underwent an operative intervention; 17,973 procedures used CO2 and 24,961 used saline solution as a distension medium. Patients were contacted after the procedure to record postprocedure symptoms suggestive of infection, including 2 or more of the following signs occurring within the 3 weeks after hysteroscopy: fever; lower abdominal pain; uterine, adnexal, or cervical motion tenderness; purulent leukorrhea; vaginal discharge or itchiness; and dysuria. Vaginal culture, clinical evaluation, transvaginal ultrasound, and histological evaluation were completed to evaluate symptoms. Measurements and Main Results Operative hysteroscopies comprised polypectomies (n = 7125; 82.0%), metroplasty (n = 731; 15.0%), myomectomy (n = 378; 7.8%), and tubal sterilization (n = 194; 4.0%). Twenty-five of the 42,934 patients (0.06%) exhibited symptoms of infection, including 24 patients (96%) with fever, 11 (45.8%) with fever as a single symptom, 7 (29.2%) with fever with pelvic pain, and 10 (41.7%) with fever with dysuria. In 5 patients with fever and pelvic pain, clinical examination and transvaginal ultrasound revealed monolateral or bilateral tubo-ovarian abscess. In these patients, histological examination from surgical specimens revealed the presence of endometriotic lesions. Conclusion The present study suggests that routine antibiotic prophylaxis is not necessary before hysteroscopy because the prevalence of infections following in-office hysteroscopy is low (0.06%).

Objectives To compare surgical outcomes of different types of intracorporeal sutures for laparoscopic posterior myomectomy, by a prospective randomized study. Study design Prospective randomized study on 47 patients with single posterior intramural myoma (4–7 cm in diameter) undergoing laparoscopic myomectomy. The patients enrolled were divided into two groups, one operated using conventional suture in double strand, and the other with bidirectional barbed suture Stratafix. The main outcome measures were suturing time, peri-operative variables, and post-operative adhesions in both groups. Results The mean operative time was shorter with the Stratafix™ than with the conventional suture (66.3 ± 8.2 vs. 73 ± 8 min; p = 0.005). Suturing time was significantly shorter in the Stratafix™ than in the control group (8.8 ± 2.4 vs. 15.5 ± 2.8 min; p = 0.001). Intraoperative bleeding was significantly less in the Stratafix group ( p = 0.0012). Conversely, there was no statistically significant difference for postoperative adhesions between the two groups (26.7% vs. 21.4% p = 0.5). Conclusions The use of barbed suture may reduce operative time, suturing time, and blood loss. No difference in post operative adhesions was found.

The dysmorphic uteri are rare Mullerian anomalies which have been always underestimated, at the beginning supposed to be present only in case of history of DES exposure, and misdiagnosed due to a lack of clear diagnostic criteria. The new classification system of uterine anomalies from the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy includes the “dysmorphic” uteri, represented by T-shaped and tubular-shaped infantilis uteri, in Class U1. Such malformations have been proven to be associated with poor reproductive performance: increased risk of adverse outcomes in pregnancy, such as preterm delivery, SGA, sore fetal presentations, infertility, and miscarriage in the early ages. The novel Hysteroscopic Outpatient Metroplasty to Expand Dysmorphic Uteri (HOME-DU) technique for dysmorphic uteri is associated with a significant improvement of the reproductive outcomes. Macroscopic uterine changes seem to be also associated with variations of endometrial micro-environment.

Vaginal lesions represent an unusual, often underestimated, cause of genital complaints. The vaginoscopic approach for hysteroscopy offers a detailed endoscopic evaluation of the vaginal canal before accessing the uterine cavity since the vaginal walls, fornices, and esocervix can be easily and accurately examined through the magnification of the images on the monitor. This approach has contributed to the development and widespread use of hysteroscopy in an office-based setting, reducing patient discomfort, and suitable for use among women who have not been sexually active or have severe vaginal atrophy or stenosis. The recent technologic advancements, with the use of miniaturized mechanical instruments and the introduction of a versatile bipolar electrosurgery system dedicated to hysteroscopy, have made possible not only diagnosing but also treating uterine, cervical, and vaginal lesions in the office setting. Vaginoscopy shouldn’t be only an easier way to get into the cervical canal, but also an important tool in the hands of the gynecologist to diagnose and treat vaginal lesions, which required more invasive and traumatic approaches.

The term Intrauterine Adhesions (IUA), refers to the presence of synechiae that can lead to a partial or total obliteration of the uterine cavity and to a modification of the normal uterine shape.1...

Hysteroscopic surgery is the actual gold standard treatment for several types of intrauterine pathologies, including submucous myomas (SMs). To date, the availability of Hysteroscopic Tissue Removal systems (HTRs) opened a new scenario. Based on these elements, the aim of this article is to review the available evidence about HTRs for the management of SMs. We included 8 papers (3 prospective studies and 5 retrospective studies). A total of 283 women underwent intrauterine morcellation of SM: 208 were treated using MyoSure and 75 using Truclear 8.0. Only 3 articles reported data about procedures performed in outpatient/office setting. Only half of the included studies included type 2 SMs. HTRs significantly reduced operative time compared to traditional resectoscopy in some studies, whereas others did not find significant differences. Despite the availability of few randomized controlled trials and the cost of the instrument, according to our systematic review, the use of HTRs seems to be a feasible surgical option in terms of operative time and complications. Nevertheless, the type of SM still remains the biggest challenge: type 0 and 1 SMs are easier to manage with respect to type 2, reflecting what already is known for the “classic” hysteroscopic myomectomy.