CASE #2

• 32 year old woman who has had one first trimester pregnancy loss presents with secondary infertility of three years duration. She has periods every 27-30 days that have become so heavy in the last year that she has become anemic and now has a hematocrit of 31. She has a normal semenanalysis, serum progesterone, clotting studies, prolactin and TSH.

CASE #2

• WHAT WOULD YOU DO NEXT?– Hysterosalpingogram?– Sonogram?– Sonohysterogram?– Office hysteroscopy?– MRI?

RIGHTUP

CERVIX

An office hysteroscopy was performed

OSTIUM

POLYP

RIGHT UTERINE HORN

FIBROID

SEPTUM

LEFT UTERINE HORN

CASE #2

• HOW WOULD YOU PREPARE HER FOR SURGERY?– No special preparation?– Oral contraceptives?– GnRH-agonist? Antagonist?– Progestin?– Danazol?– Bowel prep?

CASE #2

• WHAT SURGICAL PROCEDURE(S) WOULD YOU PERFORM?

– LAPAROTOMY? – LAPAROSCOPY?– HYSTEROSCOPY?

UTERUS

BLADDER

WHAT IS THIS?

cul de sac

U/S ligaments

uterus

CASE #2

• AFTER OBSERVING THESE FINDINGS WHAT ADDITIONAL PROCEDURES WOULD YOU PERFORM?– NONE?– ELECTROSURGERY?– LASER ABLATION?– EXCISION?

CASE #2

• HOW WOULD YOU APPROACH THE INTRA-UTERINE FINDINGS?

– HYSTEROSCOPIC REMOVAL OF FILLING DEFECTS AND INCISION OF THE SEPTUM

OR

– METROPLASTY AT LAPAROTOMY WITH REMOVAL OF FILLING DEFECTS

CASE # 1

• After removal of the septum, a polyp and a fibroid she conceived and delivered a baby girl at 39 weeks. Two years later she again developed menorrhagia and had a hysteroscopic resection of a fibroid. She conceived a second time and delivered at 41 weeks.