Hum. Reprod. Advance Access originally published online on October 13, 2006
Human Reproduction 2006 21(12):3282-3286; doi:10.1093/humrep/del299
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The occurrence and outcome of 39 pregnancies after 1621 cases of transcervical resection of endometrium
1 Hysteroscopic Center, Fuxing Hospital Affiliate of Capital University of Medical Sciences, Beijing, China and 2 The Jessop Wing, Royal Hallamshire Hospital, Sheffield, UK
3 To whom correspondence should be addressed at: Hysteroscopic Center, Fuxing Hospital Affiliate of Capital University of Medical Sciences, Beijing 100038, China. E-mail: xiaenlan{at}public.bta.net.cn
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Abstract |
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BACKGROUND: To evaluate the outcomes and management of pregnancy after transcervical resection of the endometrium (TCRE). METHODS: Retrospective study of 39 pregnancies after 1621 procedures of TCRE. RESULTS: Among 1621 women who were successfully followed up after TCRE, there were 39 pregnancies in 32 women, including five ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.6%) occurred within the first 2 years. In the first year after TCRE, the incidence of pregnancy was 1.5%. 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 have period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. Only 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 risk, and clinicians should be aware of the various complications of pregnancy that may occur after TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance.
Key words: complication/ectopic pregnancy/endometrial resection/pregnancy/termination
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Introduction |
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Transcervical resection of the endometrium (TCRE) is a common gynaecological procedure used to manage dysfunctional uterine bleeding. It is thought that the intrauterine adhesion and scar formation following TCRE will prevent embryo implantation. However, pregnancies have been reported to occur following 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 study, we report on the incidence of pregnancy and the outcome of these pregnancies in a teaching hospital in China. |
Materials and methods |
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This retrospective study was carried at Fuxing Hospital in Beijing, China. The hospital has a hysteroscopic centre which carries out
400 hysteroscopic operations per year. From the hospital records, 1621 women who had attended follow-up after TCRE between May 1990 and January 2005 were included in the study. Before the surgery, women were counselled that endometrial ablation did not guarantee contraception. They were advised to continue to use reliable contraception. Laparoscopic sterilization was offered, but none of the women took up the offer (see Discussion).
During the TCRE procedures, the endometrium with its functional layer, basal layer and the underneath 1–3-mm superficial myometrium was resected with the use of a 9-mm Olympus resectoscope, with cutting and coagulating power set at 80 and 60W, respectively. Five percentage glucose or mannitol was used as a distension medium. After the operation, patients were contacted routinely at 6 months by telephone or letter, in addition to yearly check-up.
The hospital record was reviewed and the occurrence of pregnancy after TCRE in this group of women was documented. The age of patient and the outcome of pregnancy, including when the pregnancy occurred after TCRE, were analysed.
The results are presented as the mean ± SD for quantitative variables and frequency (percentage) for qualitative variables.
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Results |
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A total of 1621 women attended follow-up visits after TCRE during the study period. The records were reviewed and the patients further contacted by post or by telephone. None of the women included in the study underwent laparoscopic sterilization procedure at the time of TCRE or afterwards. In addition, none of them used the intrauterine contraceptive device after the procedure. The duration of follow-up after TCRE ranged from 1 year to 14 years and 8 months, with a mean of 8.9 ± 3.6 years. In total, 32 women conceived after the procedures; seven women conceived twice, giving rise to a total number of 39 pregnancies (39/1621; 2.4%), the mean age of these 32 women was 39.0 ± 3.8 years (32–47 years). The outcomes of the pregnancies are shown in Figure 1. Seven pregnancies occurred in the initial 100 patients following the procedure of TCRE (7/100; 7%) and 32 pregnancies in the other 1521 patients (32/1521; 2.1%). The mean time interval between the procedure and conception was 1.3 ± 0.3 years (3–56 months).
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Among the 1621 women who underwent TCRE, 676 women (41.7%) had amenorrhoea, whereas the remaining 945 women (58.3%) continued to have period. Among 32 patients who conceived following resection, only two patients (6.2%) had amenorrhoea after TCRE (Table I). Two-by-two contingency table analyses suggested a significant (P < 0.001) negative association between conception following 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 have period (30/945; 3.2%).
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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 first case, the patient experienced acute abdominal pain 2 years after TCRE and underwent emergency laparotomy and salpingectomy for a ruptured right isthmic tubal pregnancy. In the second case, 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 artificial suction. By examining the resected uterus, the uterine cavity was obliterated by adhesions, and gestational sac was 3.5 cm in diameter, located at the right corner of uterus. The distance between the outer brim of gestational sac and serosa was only 5 mm. In another case, a woman with left cornual pregnancy underwent laparoscopic subtotal hysterectomy.
The fifth case was a cervical pregnancy that occurred 5 years after TCRE. There was profuse bleeding during suction evacuation under ultrasound guidance, and the bleeding was controlled by Foley balloon tamponade.
Termination of pregnancies
Of the 34 intrauterine pregnancies, 32 cases were terminated at the patient’s request, including two difficult procedures. In one 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, there was heavy arterial bleeding after the gestational sac was aspirated by suction. The estimated amount of bleeding was 700 ml. The bleeding was controlled, as 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 under ultrasound guidance.
Spontaneous miscarriage
There was only one pregnancy in our study which resulted in spontaneous miscarriage followed by curretage.
Term pregnancy with placenta increta
In the remaining intrauterine pregnancy, the woman opted to keep the pregnancy, which progressed to term (Figure 1). Antenatal care was provided in another hospital 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 by histopathology.
Surgery–conception interval
The number of pregnancies each year after TCRE was analysed, and the result is summarized in Table II. It appears that 84.6% of all pregnancies occurred within 2 years after the procedures.
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Discussion |
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The incidence of pregnancy after endometrial resection
After endometrial resection, the cell lining of the uterine cavity is replaced with fibrotic tissue, with a cuboidal epithelium lying directly on the myometrium, and the shape of the uterine cavity is shortened and narrowed, which is not 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, we reported 39 clinical pregnancies among 32 subjects following 1621 cases of TCRE, with a follow-up duration of 8.9 ± 3.6 years. In the literature, there have been numerous case reports of pregnancy following TCRE (Hill and Maher, 1992; Baumann et al., 1994; Edwards et al., 1996; Carpenter et al., 1998; Abdel-Fattah et al., 2003). It is also recognized that successful pregnancy may occur following other forms of endometrial ablation such as laser (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 time, 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 time of TCRE. In our studies, carried out in China, none of the women who underwent TCRE had laparoscopic sterilization, mainly because laparoscopic sterilization procedure is not popular in China. Also, few women adopt any other form of contraception after TCRE. This long-term follow-up study therefore provided a unique opportunity to observe and determine the likelihood of spontaneous conception after 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, after 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, we have detailed, long-term follow-up data, which allowed us to calculate the rate of conception per women-year, which is 39/(1621 x 8.9) = 0.27%. In the first year, however, the rate of conception per women-year was 1.5%. The result may be compared with the ones usually quoted for condom (3%, Warner and Hatcher, 1998), intrauterine contraceptive device (up to 0.2%, Luukkainen and Toivonen, 1995), combined oral contraceptives (0.1%, 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 two tubal pregnancies, one cornual pregnancy and one cervical pregnancy. Dicker et al. (1985) also reported five cervical pregnancies following endometrial ablation, of which two showed severe endometrial adhesions, which may have contributed to the cause of the cervical pregnancy. In our series, we observed five cases of ectopic pregnancy amongst 39 pregnancies. The ectopic pregnancy rate is therefore 5/39 = 12.8%, which is higher than the estimated rate of 1.15% (Tay et al., 2000)—2.07% (Stephen et al., 2005) in the general population. The ectopic pregnancy rate in our series is also much higher than the 1.4% reported by Hare and Olah (2005) following endometrial ablation. Following endometrial resection, implantation within the uterine cavity is impaired, but the procedure, like that of the intrauterine contraceptive device, does not affect fertilization and therefore the likelihood of ectopic pregnancy. The clinical implication of the finding in our series is that clinicians must be aware of the high risk of ectopic pregnancy in women who conceive following endometrial resection, and steps must be taken to verify the location of the pregnancy as soon as possible.
Termination of pregnancy
Many, but not 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 situation may be rather difficult, owing to the fibrosis involving the uterine cavity. The cavity may be contracted and irregular, which may render sounding and dilation more difficult. We therefore advocate the routine use of ultrasound guidance in performing suction termination of pregnancy following endometrial ablation. With such an approach, we were able to reduce the complication rate, with no incidence of perforation of the uterus and only one case of significant haemorrhage. In this particular case, 700 ml of bleeding occurred after the gestational sac was aspirated by suction, and the bleeding was later controlled by Foley balloon tamponade.
It is possible, nowadays, to achieve termination of pregnancy by medical means, for example by using a combination of antiprogestin and prostaglandin analogue. We have not used medical means in our series because we were concerned about the efficacy of medical termination in pregnancies after TCRE. It is possible that, owing to the fibrotic process affecting the uterine cavity, partial separation and retained product of conception are more likely to occur, resulting in an increased likelihood of haemorrhage and failure. It will be of interest to conduct 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 address the issue of obstetric outcomes after TCRE, with only one case of pregnancy which progressed beyond 20 weeks, from the data summarized by Hare and Olah (2005), of 31 pregnancies of 
20-week gestation following endometrial ablation by various techniques, 13 pregnancies (42%) delivered prematurely and 18 (58%) delivered at term, including only four (13%) absolutely normal pregnancies. Three of the preterm infants had intrauterine growth restriction (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 among 58 patients (5.2%) following intrauterine balloon ablation, with two spontaneous abortions and a placenta accreta. In our study, the only 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 by uterine synechiae resulting from an endometrial ablation. Another potential serious complication is uterine rupture during pregnancy. However, 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.
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Conclusion |
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It is important to realize that endometrial ablation itself is not a form of effective contraception. Patients should be carefully counselled about the risk of pregnancy and the various complications of pregnancy that may occur after TCRE. Clinicians must be aware of the increased likelihood of ectopic pregnancy should a woman conceive after TCRE. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance. Late 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 better than cure, women contemplating endometrial ablation should be advised of the need for effective contraception.
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References |
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Submitted on April 11, 2006; resubmitted on June 26, 2006; accepted on June 30, 2006.
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