Abstract

BACKGROUND: To evaluate the outcomes and direction of pregnancy after transcervical resection of the endometrium (TCRE). METHODS: Retrospective written report of 39 pregnancies after 1621 procedures of TCRE. RESULTS: Among 1621 women who were successfully followed up later on TCRE, there were 39 pregnancies in 32 women, including v ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.six%) occurred within the get-go 2 years. In the showtime year after TCRE, the incidence of pregnancy was 1.5%. In women who had amenorrhoea after TCRE, the chances of formulation (ii/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to take period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. But one pregnancy in our study resulted in spontaneous miscarriage which was managed by suction curettage. One term pregnancy had placenta increta resulting in Caesarean hysterectomy. CONCLUSIONS: Pregnancies after TCRE are associated with increased take chances, and clinicians should be aware of the various complications of pregnancy that may occur afterward TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a hard procedure and should be carried out under ultrasound guidance.

Introduction

Transcervical resection of the endometrium (TCRE) is a mutual gynaecological process used to manage dysfunctional uterine bleeding. It is idea that the intrauterine adhesion and scar formation following TCRE volition preclude embryo implantation. Nevertheless, pregnancies accept been reported to occur post-obit TCRE and other forms of endometrial ablation ( Baumann et al., 1994; Goldberg, 1994; Carter and Lindsay, 1997; Browne, 1999; Pugh et al., 2000; Abdel-Fattah et al., 2003; Kir and Hanlon-Lundberg, 2004). In this longitudinal report, we report on the incidence of pregnancy and the issue of these pregnancies in a teaching infirmary in Cathay.

Materials and methods

This retrospective report was carried at Fuxing Hospital in Beijing, China. The infirmary has a hysteroscopic centre which carries out ∼400 hysteroscopic operations per year. From the infirmary records, 1621 women who had attended follow-up after TCRE betwixt May 1990 and January 2005 were included in the study.

Earlier the surgery, women were counselled that endometrial ablation did not guarantee contraception. They were advised to continue to employ reliable contraception. Laparoscopic sterilization was offered, simply none of the women took up the offer (encounter Discussion).

During the TCRE procedures, the endometrium with its functional layer, basal layer and the underneath i–3-mm superficial myometrium was resected with the use of a 9-mm Olympus resectoscope, with cut and coagulating power prepare at 80 and 60W, respectively. Five percentage glucose or mannitol was used every bit a distension medium. After the operation, patients were contacted routinely at half dozen months past phone or letter of the alphabet, in improver to yearly check-up.

The hospital record was reviewed and the occurrence of pregnancy subsequently TCRE in this group of women was documented. The age of patient and the issue of pregnancy, including when the pregnancy occurred after TCRE, were analysed.

The results are presented equally the mean ± SD for quantitative variables and frequency (percentage) for qualitative variables.

Results

A full of 1621 women attended follow-upwards visits afterwards TCRE during the study period. The records were reviewed and the patients further contacted past post or by phone. None of the women included in the study underwent laparoscopic sterilization procedure at the time of TCRE or afterwards. In add-on, none of them used the intrauterine contraceptive device afterward the process. The duration of follow-up after TCRE ranged from one twelvemonth to 14 years and 8 months, with a mean of viii.9 ± 3.6 years. In full, 32 women conceived after the procedures; seven women conceived twice, giving rise to a total number of 39 pregnancies (39/1621; 2.four%), the hateful age of these 32 women was 39.0 ± iii.8 years (32–47 years). The outcomes of the pregnancies are shown in Figure 1. 7 pregnancies occurred in the initial 100 patients following the process of TCRE (7/100; 7%) and 32 pregnancies in the other 1521 patients (32/1521; two.1%). The mean fourth dimension interval betwixt the procedure and conception was 1.3 ± 0.iii years (3–56 months).

Effigy 1.

A summary of the outcome of 39 pregnancies after 1621 cases of endometrial resection.

A summary of the outcome of 39 pregnancies after 1621 cases of endometrial resection.

Figure ane.

A summary of the outcome of 39 pregnancies after 1621 cases of endometrial resection.

A summary of the upshot of 39 pregnancies afterward 1621 cases of endometrial resection.

Among the 1621 women who underwent TCRE, 676 women (41.7%) had amenorrhoea, whereas the remaining 945 women (58.3%) continued to take menses. Among 32 patients who conceived following resection, simply two patients (6.2%) had amenorrhoea subsequently TCRE (Tabular array I). Ii-by-2 contingency table analyses suggested a significant (P < 0.001) negative clan betwixt conception post-obit TCRE and amenorrhoea. In women who had amenorrhoea after TCRE, the chances of conception (2/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to take flow (thirty/945; 3.2%).

Table I.

The relationship between menstruation and conception subsequently transcervical resection of the endometrium (TCRE)

Women who had amenorrhoea Women who continued to have period Total
Pregnancy 2 xxx 32
Non-pregnancy 674 915 1589
Total 676 945 1621
Women who had amenorrhoea Women who continued to accept period Total
Pregnancy 2 30 32
Non-pregnancy 674 915 1589
Total 676 945 1621

Table I.

The human relationship betwixt catamenia and conception after transcervical resection of the endometrium (TCRE)

Women who had amenorrhoea Women who continued to have period Total
Pregnancy 2 30 32
Non-pregnancy 674 915 1589
Total 676 945 1621
Women who had amenorrhoea Women who connected to have period Total
Pregnancy 2 30 32
Not-pregnancy 674 915 1589
Full 676 945 1621

Location of pregnancies

There were 39 pregnancies, of which five were ectopic pregnancies and 34 were intrauterine pregnancies.

Among the five ectopic pregnancies, there were two tubal pregnancies. In the showtime case, the patient experienced acute abdominal pain 2 years afterward TCRE and underwent emergency laparotomy and salpingectomy for a ruptured correct isthmic tubal pregnancy. In the 2d instance, the patient had a chronic tubal pregnancy and underwent laparotomy and salpingectomy.

There were two cornual pregnancies. In one case, subtotal hysterectomy was performed after a failed bogus suction. By examining the resected uterus, the uterine crenel was obliterated by adhesions, and gestational sac was three.v cm in bore, located at the right corner of uterus. The altitude between the outer skirt of gestational sac and serosa was only 5 mm. In some other example, a adult female with left cornual pregnancy underwent laparoscopic subtotal hysterectomy.

The fifth case was a cervical pregnancy that occurred five years afterwards TCRE. There was profuse bleeding during suction evacuation under ultrasound guidance, and the haemorrhage was controlled past Foley balloon tamponade.

Termination of pregnancies

Of the 34 intrauterine pregnancies, 32 cases were terminated at the patient's request, including two hard procedures. In 1 case, there was difficulty in dilation because of significant intrauterine adhesion. Hysteroscopic adhesiolysis was carried out, followed by the successful introduction of the suction curettage and removal of the gestational sac. In another case, in that location was heavy arterial haemorrhage after the gestational sac was aspirated by suction. The estimated amount of bleeding was ∼700 ml. The bleeding was controlled, every bit in the case of the cervical pregnancy, by inserting a Foley balloon to tampon the uterine cavity. For the remaining 30 pregnancies that were terminated, suction termination was performed smoothly nether ultrasound guidance.

Spontaneous miscarriage

In that location was simply one pregnancy in our study which resulted in spontaneous miscarriage followed past curretage.

Term pregnancy with placenta increta

In the remaining intrauterine pregnancy, the adult female opted to keep the pregnancy, which progressed to term (Effigy 1). Antenatal intendance was provided in another infirmary outside Beijing. Caesarean section was performed at 39 gestational weeks at patient's request, and a 2500-g live girl was delivered. The placenta was morbidly adherent to the uterine wall, leading to a subtotal hysterectomy. Placenta increta which was not diagnosed antenatally was confirmed past histopathology.

Surgery–formulation interval

The number of pregnancies each year later on TCRE was analysed, and the result is summarized in Tabular array Ii. It appears that 84.6% of all pregnancies occurred within 2 years later on the procedures.

Tabular array 2.

The occurrence and location of pregnancies in each year after transcervical resection of the endometrium (TCRE)

The time interval between TCRE and conception Cases with pregnancy (n) Location of pregnancies
Intrauterine crenel (n) Fallopian tube (n) Uterine cornua (n) Neck (n)
First year 25 25 0 0 0
Second year 8 iv 2 2 0
Third year 3 three 0 0 0
Along year 2 2 0 0 0
Fifth year 1 0 0 0 i
The time interval between TCRE and conception Cases with pregnancy (n) Location of pregnancies
Intrauterine crenel (n) Fallopian tube (n) Uterine cornua (north) Cervix (north)
Start year 25 25 0 0 0
2nd yr viii 4 2 2 0
3rd year 3 3 0 0 0
Along yr 2 2 0 0 0
5th year 1 0 0 0 1

Table II.

The occurrence and location of pregnancies in each year later on transcervical resection of the endometrium (TCRE)

The time interval betwixt TCRE and conception Cases with pregnancy (northward) Location of pregnancies
Intrauterine cavity (northward) Fallopian tube (north) Uterine cornua (n) Cervix (n)
First year 25 25 0 0 0
2nd year 8 4 two ii 0
3rd yr 3 three 0 0 0
Forth year 2 ii 0 0 0
Fifth year 1 0 0 0 ane
The time interval betwixt TCRE and conception Cases with pregnancy (n) Location of pregnancies
Intrauterine cavity (n) Fallopian tube (n) Uterine cornua (n) Neck (n)
Get-go yr 25 25 0 0 0
2nd year 8 iv 2 two 0
Third year 3 3 0 0 0
Forth year 2 2 0 0 0
Fifth year 1 0 0 0 1

Discussion

The incidence of pregnancy after endometrial resection

Afterwards endometrial resection, the jail cell lining of the uterine crenel is replaced with fibrotic tissue, with a cuboidal epithelium lying directly on the myometrium, and the shape of the uterine crenel is shortened and narrowed, which is non usually conducive to successful implantation. However, the ability of endometrium to regenerate is enormous; focal regeneration of residual endometrium may, in some case, permit the embryo to implant.

In our study, nosotros reported 39 clinical pregnancies among 32 subjects following 1621 cases of TCRE, with a follow-upwardly duration of 8.9 ± 3.six years. In the literature, in that location have been numerous instance reports of pregnancy post-obit TCRE (Colina and Maher, 1992; Baumann et al., 1994; Edwards et al., 1996; Carpenter et al., 1998; Abdel-Fattah et al., 2003). It is besides recognized that successful pregnancy may occur post-obit other forms of endometrial ablation such every bit light amplification by stimulated emission of radiation ( Garry et al., 1995; Pinette et al., 2001; Hare and Olah, 2005), rollerball (Carter and Lindsay, 1997; Browne, 1999; Cook and Seman, 2003) and thermal balloon ( Gervaise et al., 1999; Kir and Hanlon-Lundberg, 2004).

For some fourth dimension, it is assumed that endometrial ablation per se is not a reliable, effective contraception. Consequently, in the early days of TCRE, women were advised to consider laparoscopic sterilization at the fourth dimension of TCRE. In our studies, carried out in Cathay, none of the women who underwent TCRE had laparoscopic sterilization, mainly because laparoscopic sterilization procedure is non popular in China. Too, few women adopt whatsoever other class of contraception after TCRE. This long-term follow-upward written report therefore provided a unique opportunity to observe and determine the likelihood of spontaneous formulation subsequently TCRE. From our data, 32 of 1621 (2%) women conceived. It agreed broadly with the report of Roy and Mattox (2002) that, based on the analysis of several previous smaller studies, the combined incidence of pregnancy, later on endometrial ablation including resection, was 0.65%.

However, the likelihood of conception after TCRE is dependent on several factors, including the duration of follow-up, age of the patient and the depth of endometrial resection. In our study, nosotros have detailed, long-term follow-upwards data, which allowed us to summate the rate of conception per women-year, which is 39/(1621 × viii.9) = 0.27%. In the first year, however, the rate of formulation per women-year was 1.5%. The result may be compared with the ones ordinarily quoted for condom (3%, Warner and Hatcher, 1998), intrauterine contraceptive device (up to 0.2%, Luukkainen and Toivonen, 1995), combined oral contraceptives (0.ane%, Hatcher and Guillebaud, 1998), long-acting steroidal contraception (0.4–0.5%, Bardin, 1989) and sterilization (0.09–0.6%, Loffer and Pent, 1980). In our study, we also found that women who developed amenorrhoea after TCRE had a much lower chance of conception (0.3%) compared with those who continued to have period (3.2%).

Location of pregnancy

Whitelaw and Sutton (1992) reported four cases of ectopic pregnancies following TCRE, including ii tubal pregnancies, one cornual pregnancy and one cervical pregnancy. Dicker et al. (1985) also reported five cervical pregnancies following endometrial ablation, of which 2 showed severe endometrial adhesions, which may have contributed to the crusade of the cervical pregnancy. In our series, nosotros observed five cases of ectopic pregnancy among 39 pregnancies. The ectopic pregnancy rate is therefore v/39 = 12.viii%, which is higher than the estimated charge per unit of 1.fifteen% ( Tay et al., 2000)—2.07% ( Stephen et al., 2005) in the full general population. The ectopic pregnancy rate in our series is too much college than the 1.iv% reported by Hare and Olah (2005) following endometrial ablation. Following endometrial resection, implantation within the uterine cavity is impaired, but the process, similar that of the intrauterine contraceptive device, does not touch on fertilization and therefore the likelihood of ectopic pregnancy. The clinical implication of the finding in our serial is that clinicians must be enlightened of the high take chances of ectopic pregnancy in women who excogitate following endometrial resection, and steps must be taken to verify the location of the pregnancy as shortly as possible.

Termination of pregnancy

Many, only non all, patients following endometrial resections have no desire for further pregnancy; hence, pregnancy termination is often considered if they conceive unexpectedly. However, termination of pregnancy in this state of affairs may exist rather difficult, owing to the fibrosis involving the uterine crenel. The cavity may exist contracted and irregular, which may return sounding and dilation more than hard. We therefore advocate the routine use of ultrasound guidance in performing suction termination of pregnancy post-obit endometrial ablation. With such an arroyo, nosotros were able to reduce the complication charge per unit, with no incidence of perforation of the uterus and only one case of significant haemorrhage. In this detail case, 700 ml of bleeding occurred subsequently the gestational sac was aspirated by suction, and the bleeding was after controlled by Foley airship tamponade.

It is possible, nowadays, to achieve termination of pregnancy by medical means, for example by using a combination of antiprogestin and prostaglandin analogue. Nosotros have not used medical means in our serial considering nosotros were concerned about the efficacy of medical termination in pregnancies after TCRE. It is possible that, attributable to the fibrotic process affecting the uterine crenel, partial separation and retained production of conception are more likely to occur, resulting in an increased likelihood of bleeding and failure. It volition exist of involvement to bear an observational study or randomized controlled trial comparing medical and surgical termination of pregnancy following TCRE to verify whether medical termination in this situation is indeed less effective and not desirable.

Obstetric outcomes after resection

Although our series does not accost the issue of obstetric outcomes after TCRE, with merely ane case of pregnancy which progressed across 20 weeks, from the data summarized by Hare and Olah (2005), of 31 pregnancies of ≥20-week gestation following endometrial ablation by diverse techniques, 13 pregnancies (42%) delivered prematurely and xviii (58%) delivered at term, including only four (13%) absolutely normal pregnancies. Three of the preterm infants had intrauterine growth brake (IUGR), and 10 of 31 pregnancies (32.3%) had a morbidly adherent placenta. The Caesarean section rate was 71% (22/31). In addition, Gervaise et al. (2005) reported three pregnancies amongst 58 patients (5.2%) post-obit intrauterine balloon ablation, with two spontaneous abortions and a placenta accreta. In our study, the simply patient with a pregnancy that progressed to term had placenta increta and subtotal hysterectomy.

Recently, Mukul and Linn (2005) reported a case of significant fetal malformations caused past uterine synechiae resulting from an endometrial ablation. Another potential serious complexity is uterine rupture during pregnancy. Notwithstanding, whilst there were cases of uterine rupture in literature following operative hysteroscopy ( Deaton et al., 1989), none of them was related to TCRE. It is unclear whether TCRE predisposes to uterine rupture during pregnancy.

Conclusion

It is important to realize that endometrial ablation itself is not a form of constructive contraception. Patients should be carefully counselled about the adventure of pregnancy and the diverse complications of pregnancy that may occur after TCRE. Clinicians must be aware of the increased likelihood of ectopic pregnancy should a woman excogitate afterwards TCRE. Surgical termination of pregnancy afterward TCRE is potentially a hard procedure and should be carried out under ultrasound guidance. Belatedly pregnancy complications are high for those whose pregnancies progressed to the third trimester. In many respects, therefore, pregnancies after TCRE are associated with increased risks. As prevention is amend than cure, women contemplating endometrial ablation should be advised of the need for effective contraception.

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