There is a balance between procedural success and patient acceptability in outpatient hysteroscopy. Reporting either outcome alone inadequately reflects how well the procedure was conducted. A new metric is proposed: the "Clark ratio", defined as patient acceptability divided by procedural failure, to capture this trade-off. Higher ratios indicate better performance. The limitations of data from randomised controlled trials and need for real-world evidence and standardised outcome measures to validate feasibility and patient experience is discussed. The Clark ratio is a new concept and could potentially be adopted, if found to be valid and useful, as a simple, easily interpretable, pragmatic benchmark for quality assurance and outcome in research for outpatient hysteroscopic procedures.
Background: Despite its widespread use in women with reproductive disorders, no standardised framework currently exists for reporting of hysteroscopic findings. This lack of uniformity may limit the utility of the procedure and contribute to substantial heterogeneity among operators and centres. As a result, the reproducibility of hysteroscopy is limited, making it difficult to conduct robust studies that define its prognostic value in specific patient subgroups. Objectives: To develop an international consensus on the structured reporting of diagnostic hysteroscopy findings in women with reproductive disorders. Methods: A dedicated working group from the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE), and International Federation of Fertility Societies (IFFS) collaborated to develop a consensus for comprehensive structured reporting of diagnostic hysteroscopy findings in women with reproductive problems. This consensus paper focuses on grouping diagnostic hysteroscopic findings, structuring their reporting, and adopting standardised terminology for women with reproductive disorders. The virtual Nominal Group Technique, a structured consensus-building method, was adopted to ensure equal contribution from all members in the development of the final consensus. Main Outcome Measures: A consensus for comprehensive structured reporting of diagnostic hysteroscopy findings in women with reproductive problems. Results: This collaborative document by ESGE, ESHRE and IFFS provides the first detailed framework for structured reporting of diagnostic hysteroscopy findings in women with reproductive disorders. The document provides a structured reporting of hysteroscopic findings into five sections, each systematically capturing patient characteristics, procedural findings, and pathological observations as follows: patient characteristics, findings from the vagina, cervix, uterine cavity, endometrium and tubal ostia. Conclusions: The standardised reporting of hysteroscopic findings promotes consistent data collection across centres and could help inform research and exchange of clinical experience, enhancing the value of hysteroscopy in fertility evaluation. This report could be used as a validation tool for further research. What is New?: This collaborative document by ESGE, ESHRE and IFFS provides the first detailed structured reporting of diagnostic hysteroscopy findings in women with reproductive disorders.
Pelvic neuropathy is an under-recognised contributor to chronic pelvic pain in women, yet a structured overview of its identifiable causes has been lacking. In this narrative review we searched PubMed, Embase and Web of Science from inception to 1 March 2024 for clinical studies describing pelvic neuropathy in women with a defined or inferable aetiology, and synthesised them thematically. We included 306 studies (215 case reports, 53 case series, 24 retrospective and 14 prospective cohort studies) describing 2,413 women. Five recurring aetiological categories emerged: iatrogenic injury (the most frequent), nerve invasion or traction by disease processes (notably endometriosis and tumours), pregnancy- and childbirth-related injury, external trauma, and compression by muscular, vascular, benign or malignant structures. Aetiologies of particular relevance to gynaecological practice included nerve-invasive endometriosis, which characteristically produces cyclical (catamenial) symptoms, and obstetric neuropathies, which are usually self-limiting. Specific neuropathic syndromes—piriformis, May–Thurner, pelvic congestion and Alcock’s canal (pudendal) syndrome—were inconsistently defined across studies. Diagnostic strategies and reporting quality varied widely, neuropathy was frequently recognised late, and the evidence base was dominated by case reports and small series; the overall certainty of evidence is therefore low and no randomised controlled trials were identified. Greater awareness of nerve-specific injury mechanisms—particularly endometriosis-related and obstetric neuropathies—together with standardised diagnostic pathways, is needed to improve recognition and outcomes for women with neuropathic pelvic pain.
Background: Adenomyosis may alter the functional architecture of the inner myometrium and has been associated with impaired reproductive outcomes. Focal cystic adenomyotic lesions can persist despite hormonal suppression and may be challenging to identify and treat hysteroscopically. Objectives: To demonstrate a reproducible, stepwise, hysteroscopic technique for the identification and management of focal cystic adenomyosis of the inner myometrium. Participant: Women with infertility and recurrent implantation failure, defined as failure to achieve a clinical pregnancy after repeated embryo transfers, diagnosed with focal cystic adenomyosis of the inner myometrium based on transvaginal ultrasound and hysteroscopic assessment. Intervention: Procedures were performed in an ambulatory digital hysteroscopy setting at the Life Expert Centre (Leuven, Belgium) under conscious sedation. The approach combined hysteroscopy and transvaginal ultrasound throughout diagnosis, treatment, and follow-up. Preoperative hormonal suppression was used to identify lesions persisting despite medical therapy. Key steps were: (1) lesion mapping using ultrasound-hysteroscopic correlation, including bipolar-marker topographic correlation of lesions not directly visible during hysteroscopy; (2) meticulous dissection and resection using 5Fr mechanical instruments and / or a bipolar loop within a 15Fr mini-resectoscope; (3) application of a crosslinked hyaluronic acid anti-adhesion barrier; and (4) structured postoperative follow-up, including second-look hysteroscopy when indicated. Conclusions: Combination of hysteroscopy and transvaginal ultrasound enables minimally invasive management of focal cystic adenomyosis of the inner myometrium. This video demonstrates a reproducible approach based on precise lesion identification, targeted treatment, and structured postoperative assessment. What is New?: This video introduces a novel technique of topographic ultrasound-hysteroscopic correlation using bipolar-marker localisation, facilitating the identification and treatment of adenomyotic cysts not directly visible during hysteroscopy.
