OBJECTIVE:To study the differences in uterine contractility in women with septate uterus compared with those with a normal uterus throughout the menstrual cycle using a quantitative two-dimensional transvaginal ultrasound speckle tracking method. DESIGN:A multicenter prospective observational study was performed from February 2023 to July 2024. SUBJECTS:Fifty-seven patients with a diagnosis of septate uterus and seventy-one patients with a normal uterus, all of reproductive age, were enrolled at the Gynecology Departments of the University of Naples Federico II (Italy) and the Catharina Hospital in Eindhoven (Netherlands). EXPOSURE:A four-minute two-dimensional transvaginal ultrasound video in a median sagittal section of the uterus was performed throughout the various phases of the menstrual cycle to evaluate uterine contractility features, using a speckle tracking algorithm. MAIN OUTCOME MEASURES:Uterine contractility features were analyzed in all patients diagnosed with a septate uterus, including contraction frequency (in contractions per minute), amplitude, direction, median velocity (mm/sec), and coordination measured in mean squared error. RESULTS:Regardless of the cycle phase, patients with a septate uterus exhibited statistically significant trends of decreased contraction frequency, velocity, and amplitude, along with poorer contraction coordination, compared with patients with normal uterus. In the luteal phase, when contractions are typically quiescent to facilitate embryo implantation, an increase in contraction frequency (1.27 ± 0.21 vs. 1.10 ± 0.12), contraction velocity in posterior wall from cervix to fundus (0.90 ± 0.23 vs. 0.70 ± 0.09), contraction velocity in posterior wall from fundus to cervix (0.91 ± 0.23 vs. 0.71 ± 0.08) and a decrease in contraction coordination (0.41 ± 0.16 vs. 0.20 ± 0.08) were reported in septate uteri. Furthermore, when considering two subgroups-partial and complete septate uteri compared with normal uteri-data indicated a greater impairment of uterine contractility in partial septate uteri when compared with normal uteri. CONCLUSION:The presence of uterine pathologies, such as a septate uterus, may alter uterine peristalsis. A deeper understanding of uterine peristalsis in congenital anomalies could illuminate the link between the septate uterus and infertility. TRIAL REGISTRATION:number NL52466.100.15.

Objective: To evaluate uterine contractility in patients with adenomyosis compared with healthy controls using a quantitative twodimensional transvaginal ultrasound (TVUS) speckle tracking method. Design: A multicenter prospective observational study took place in three European centers between 2014 and 2023. Setting: One university teaching hospital, 1 teaching hospital and 1 specialised clinic. Patients: A total of 46 women with a sonographic or magnetic resonance imaging diagnosis of adenomyosis were included. 106 healthy controls without uterine pathologies were included. Intervention: Four -minute TVUS recordings were performed and four uterine contractility features were extracted using a speckle tracking algorithm. Main Outcomes Measures: The extracted features were contraction frequency (contractions/min), amplitude, velocity (mm/s), and coordination. Women with adenomyosis were compared with healthy controls according to the phase of the menstrual cycle. Results: Throughout the different phases of the menstrual cycle, trends of increased amplitude, decreased frequency and velocity, and reduced contraction coordination were seen in patients with adenomyosis compared with healthy controls. These were statistically signi fi cant in the late follicular phase, with a higher amplitude (0.087 +/- 0.042 vs. 0.050 +/- 0.018), lower frequency and velocity (1.49 +/- 0.22 vs. 1.68 +/- 0.25 contractions/min, and 0.65 +/- 0.18 vs. 0.88 +/- 0.29 mm/s, respectively), and reduced contraction coordination (0.34 +/- 0.08 vs. 0.26 +/- 0.17), in the late luteal phase, with higher amplitude (0.050 +/- 0.022 vs. 0.035 +/- 0.013), lower velocity (0.51 +/- 0.11 vs. 0.65 +/- 0.13 mm/s), and reduced contraction coordination (0.027 +/- 0.06 vs. 0.18 +/- 0.07), and in the midfollicular phase, with decreased frequency (1.48 +/- 0.21 vs. 1.69 +/- 0.16 contractions/min) in patients with adenomyosis compared with healthy controls. During menses, a higher pain score was signi fi cantly associated with lower frequency and velocity and higher contraction amplitude. Results remained signi fi cant after correcting for age, parity, and body mass index. Conclusion: Uterine contractility differs in patients with adenomyosis compared with healthy controls throughout the phases of the menstrual cycle. This suggests an etiologic mechanism for the infertility and dysmenorrhea seen in patients with adenomyosis. Moreover, it presents new potential therapeutic targets and diagnostic markers. (Fertil Steril e 2024;121:864 - 72. (c) 2024 by American Society for Reproductive Medicine.)

BACKGROUND:Traditionally, curettage has been the most widely performed surgical intervention for removing retained products of conception. However, hysteroscopic removal is increasingly performed as an alternative because of the potentially lower risk of intrauterine adhesions and higher rates of complete removal. Until recently, studies comparing curettage with hysteroscopic removal regarding reproductive and obstetrical outcomes were limited, and data conflicting. OBJECTIVE:This study aimed to assess reproductive and obstetrical outcomes in women wishing to conceive after removal of retained products of conception by hysteroscopy or ultrasound-guided electric vacuum aspiration. STUDY DESIGN:This was a prospective long-term follow-up study, conducted in 3 teaching hospitals and 1 university hospital. Patients were included from April 2015 until June 2022 for follow-up, either in a randomized controlled, nonblinded trial on the risk of intrauterine adhesions after removal of retained products of conception, or in a cohort alongside the randomized trial. Women with an ultrasonographic image suggestive of retained products of conception ranging from 1 to 4 cm were eligible. Surgical procedures in the randomized controlled trial were hysteroscopic morcellation or ultrasound-guided electric vacuum aspiration. In the cohort study, hysteroscopic treatment included hysteroscopic morcellation or cold loop resection compared with ultrasound-guided electric vacuum aspiration. RESULTS:A total of 261 out of 305 patients (85.6%) were available for follow-up after removal of retained products of conception, resulting in a cohort of 171 women after hysteroscopic removal and 90 women after removal by ultrasound-guided vacuum aspiration. Respectively, 92 of 171 women (53.8%) in the hysteroscopic removal group and 56 of 90 (62.2%) in the electric vacuum aspiration group wished to conceive (P=.192). Subsequent pregnancy rates were 88 of 91 (96.7%) after hysteroscopic removal and 52 of 56 (92.9%) after electric vacuum aspiration (P=.428). The live birth rates were 61 of 80 (76.3%) and 37 of 48 (77.1%) after hysteroscopic removal and electric vacuum aspiration, respectively (P=.914), with 8 of 88 pregnancies (9.1%) in the hysteroscopic removal group and 4 of 52 (7.7%) in the electric vacuum aspiration group still ongoing at follow-up (P=1.00). The median time to conception was 8.2 weeks (interquartile range, 5.0-17.2) in the hysteroscopic removal group and 6.9 weeks (interquartile range, 5.0-12.1) in the electric vacuum aspiration group (P=.262). The overall placental complication rate was 13 of 80 (16.3%) in the hysteroscopic removal group and 11 of 48 (22.9%) in the electric vacuum aspiration group (P=.350). CONCLUSION:Hysteroscopic removal and ultrasound-guided electric vacuum aspiration of retained products of conception seem to have no significantly different effects on subsequent live birth rate, pregnancy rate, time to conception, or pregnancy complications. Reproductive and obstetrical outcomes after removal of retained products of conception are reassuring, albeit with a high risk of placental complications.

Study Objective To develop a machine learning framework for improved prediction of in-vitro fertilization (IVF) success based on quantitative uterine motion features characterizing myometrial peristalsis. Design Multi-centre prospective observational cohort study. Setting Multiple fertility centers in three different international clinical settings. Patients or Participants 64 IVF/ICSI patients undergoing fresh embryo transfer from participating centres. Interventions Each patient underwent a four-minute B-mode transvaginal ultrasound (TVUS) scans performed one hour before embryo transfer (ET). 23 features related to frequency, amplitude, power, velocity, and coordination were extracted using strain analysis from TVUS speckle tracking results. Three probabilistic classifiers, i.e., support vector machine (SVM), K-nearest neighbors (KNN), and adaptive boosting (AdaBoost), were employed to discriminate uterine activity as either favourable or adverse to ongoing pregnancy rate (positive foetal heartbeat at 11 weeks gestation). Prior to machine learning, feature selection was performed by correlation filtering, least absolute shrinkage and selection operator regression, and sequential forward selection. The proposed method was evaluated by a nested 8-fold cross validation. Measurements and Main Results Age, BMI, type of treatment, stimulation protocol, duration of infertility, number of previous IVF cycles, gravidity and parity did not differ statistically significantly between pregnant and non-pregnant groups (p>0.05).Our results suggest that features related to coordination, velocity and frequency of the uterine peristalsis are strongly associated with clinical pregnancy, and SVM demonstrates the best classification performance between successful and unsuccessful pregnancies, with an average area under the receiver operating characteristic curve of 0.81. Conclusion We developed a machine learning framework to improve the prediction of IVF outcome based on TVUS recordings of patients from multiple centers. Our SVM model identified significant uterine motion features and demonstrated reliable and generalisable classification performance. This work can provide useful means to support clinicians for clinical decision-making prior to ET and possibly enhance IVF success rates.

Abstract Study question Comparison of uterine contractility (UC) in adenomyosis patients (AP) with and without hormonal contraception (HC) compared to controls with HC, measured by transvaginal ultrasound (TVUS). Summary answer AP with HC show better contraction coordination compared to untreated AP. AP with HC show comparable UC compared to controls with HC. What is known already Adenomyosis is a disease of the uterus that can cause dysmenorrhoea, menorrhagia, dyspareunia and subfertility. These symptoms could be explained by the different contraction patterns in women with adenomyosis compared to healthy controls. Therapeutic use of hormonal contraception reduces the symptoms experienced by women with adenomyosis. This could be explained by the normalization of contraction patterns, which has not yet been objectively quantified due to the absence of a suitable measurement tool. A novel speckle-tracking and strain analysis by 2D TVUS recordings has recently been used to assess differences in contraction coordination, contraction frequency, velocity and direction in healthy women. Study design, size, duration This study is part of an ongoing multi-centre prospective observational cohort study investigating UC on TVUS. Our study includes the TVUS recordings of 23 women with adenomyosis without hormonal contraception treatment, 15 women with adenomyosis undergoing hormonal contraception treatment, and 17 women with healthy uteri undergoing hormonal contraception treatment. Patients were included in 3 centres from 2017 to 2023 (Catharina Hospital Eindhoven, Fertility Clinic Thessaloniki and University Federico Napels). Participants/materials, setting, methods 23 women with sonographic suspicion of adenomyosis without HC, 15 women with adenomyosis undergoing HC treatment and 17 women with healthy uteri with HC were included. HC included oral combined HC, progesterone only pill and hormonal IUD. UC frequency, amplitude, velocity and coordination were assessed by applying a dedicated speckle-tracking and strain analysis to 2-4-minute TVUS recordings in midsagittal section. AP with HC were compared to AP without contraception and to healthy controls with HC. Main results and the role of chance Age, BMI, parity and uterus volume were significantly higher in the women with adenomyosis compared to the healthy controls (p < 0.05). The adenomyosis group with contraception showed more contraction coordination compared to the adenomyosis group without hormonal contraception treatment (0.23 ± 0.10 vs. 0.29 ± 0.11, p = 0.041). There was a tendency towards higher contraction frequency (1.53 ± 0.21 vs. 1.42, p = 0.153) and lower amplitude (0.56 ± 0.04 vs. 0.65 ± 0.04, p = 0.159) in the adenomyosis group with hormonal contraception treatment compared to the adenomyosis group without hormonal contraception treatment. There were no significant differences in uterine contractility between the adenomyosis group with hormonal contraception treatment compared to the healthy group with hormonal contraception treatment. Limitations, reasons for caution No sub-analysis was done to assess effects of additional adenomyosis and contraception characteristics due to this being an ongoing study. Women with extensive adenomyosis were not included due to impossibility to perform analysis of ultrasound recordings. AP were older, had higher BMI and larger uterus volumes than healthy controls. Wider implications of the findings The normalization of UC under therapeutic use of HC compared to untreated AP and the lack of differences in UC between AP and healthy controls with HC, confirms the therapeutic effect on adenomyotic symptoms. This presents a new therapeutic efficacy marker for adenomyosis. Trial registration number NL52466.100.15

Abstract Study question Description of uterine contractility characteristics in adenomyosis patients compared to healthy controls and according to degree of dysmenorrhoea measured by quantitative 2D transvaginal ultrasound (TVUS). Summary answer Women with adenomyosis show differences in uterine contraction patterns (frequency, amplitude, velocity, and contraction coordination) compared to healthy controls and depending on degree of dysmenorrhoea. What is known already The natural contraction pattern of the uterus changes throughout the menstrual cycle in response to cyclic changes in hormones. In abnormal uteri, such as adenomyotic uteri, this response may be different. Adenomyosis can cause dysmenorrhoea, menorrhagia, dyspareunia, and subfertility. These symptoms could be explained by different contraction patterns of the uterus, however, this has not yet been objectively quantified due to the absence of a suitable measurement tool. Recently, speckle-tracking and strain analysis of 2D TVUS was used to assess differences in contraction coordination, frequency, velocity, and direction, depending on the phase of the menstrual cycle in healthy women. Study design, size, duration This study is part of an ongoing multi-centre prospective observational cohort study investigating uterine contractility in TVUS recordings. Our study includes the TVUS recordings of 31 women with adenomyosis and 106 women with healthy uteri. Patients were included in 3 centres from 2017 to 2023 (Netherlands, Greece, Italy). Participants/materials, setting, methods 31 women with sonographic suspicion of adenomyosis and 106 women with healthy uteri with natural menstrual cycles were included. Uterine contraction frequency, amplitude, velocity, and coordination were assessed by applying a dedicated speckle tracking and strain analysis to 2-4-minute TVUS recordings in midsagittal section. Degree of dysmenorrhoea was measured according to visual analogue score (VAS). Women with suspicion of adenomyosis were compared to women with healthy uteri according to the phase of their menstrual cycle. Main results and the role of chance Age, BMI, parity and uterus volume were significantly higher in the women with adenomyosis compared to the healthy controls (p < 0.05). Uterine contractility differed between women with adenomyosis and healthy controls during the periovulatory phase, revealing lower frequency (1.50±0.25 vs. 1.75±0.35, p = 0.031), higher amplitude (0.076±0.039 vs. 0.046±0.018, p = 0.001), and lower velocity (0.64±0.18 vs. 0.84±0.22, p = 0.020) of uterine contractions in the group with adenomyosis patients. In the late luteal phase, women with adenomyosis showed higher amplitude (0.050±0.02 vs. 0.035±0.01, p = 0.039) and lower velocity (0.51±0.11 vs. 0.72±0.16, p = 0.032) than the healthy controls. During menstruation, women with adenomyosis showed a trend towards higher contraction amplitude (0.044± 0.01 vs. 0.037±0.01, p = 0.051) compared to healthy controls. During the menstrual, periovulatory and late luteal phase, women with adenomyosis showed reduced contraction coordination (p = 0.047, p = 0.015 and p = 0.011, respectively) compared to healthy controls. Increased dysmenorrhoea (VAS score) in overall adenomyosis patients was associated with lower contraction velocity (p = 0.043) and a tendency towards lower frequency (p = 0.160) and higher amplitude (p = 0.154). Limitations, reasons for caution No sub-analysis was done to assess effects of additional adenomyosis characteristics (i.e. adenomyosis severity, adenomyosis type, adenomyosis location). Women with extensive adenomyosis were not included due to impossibility to perform analysis of ultrasound images. Women with adenomyosis were older, had higher BMI and larger uterus volumes than healthy controls. Wider implications of the findings Uterine contractility differs between patients with adenomyosis versus healthy women throughout the menstrual cycle. More dysmenorrhoea in adenomyosis patients was also associated with a different contractility pattern. This suggests an aetiological mechanism for the clinical presentation of adenomyosis (i.e. dysmenorrhoea and subfertility) and presents potential therapeutic markers. Trial registration number NL52466.100.15

To assess the effect of intrauterine device (IUD) insertion of uterine contractility (UC), and to assess the relationship between UC and patient pain experience. 28 (out)patients undergoing IUD insertion were included in analysis for this ongoing prospective cohort study. Each patient underwent a 4-minute transvaginal ultrasound (TVUS) measurement of the uterus in mid-sagittal section directly prior to, and directly after, IUD placement. VAS scores for pain were collected at time of placement. TVUS recordings were analysed using an automated 2D speckle-tracking method to collect data on uterine contraction frequency (CF, contractions/minute), amplitude, velocity (mm/sec), and co-ordination. Patients were included regardless of hormonal therapy and cycle phase. Between-subject analysis was conducted using the independent t-test and/or shapiro-wilk test depending on normality, and within-subject analysis using the paired t-test. Patient VAS scores were stratified to mild and/or moderate pain (VAS below 7) and severe pain (VAS of 7 or higher). Mean age was 31.6 years (SD ± 11.3), most patients were nulliparous (17/28). 17/28 patients were using oral hormonal contraction at time of IUD insertion. Mean uterine length was 67.2mm (SD ± 12.0). Median reported VAS was 7.00 (IQR 3.00). Only CF increased after IUD placement (pre-IUD 1.50 (SD ±0.35) vs. post-IUD 1.70 (SD ±0.30), p < 0.001). No other UC features were affected bij IUD insertion (P > 0.05). Patients with a severe VAS showed higher CF (1.64 (SD ± 0.56) vs. 1.48 (SD ±0.20), p = 0.025) and a lower contraction amplitude (35.9 (SD ±3.0) vs. 25.7 (SD ±11.3)), p = 0.013). UC is affected bij IUD insertion, with initial analyses pointing towards (changes in) specific uterine features and patient pain experience. Namely uterine contraction frequency and amplitude difference may be most involved in pain experience associated with IUD insertion. Future studies should investigate the effect of cycle phase, parity and potential uterine pathologies on pain sensation, and confirm these findings in a larger population.

Study objective: The aim of this study was to characterise the severity of adenomyosis on MRI in infertile women, and to assess if MRI characteristics of adenomyosis severity are associated with worse IVF/ICSI pregnancy outcomes versus male infertility controls.Materials and methods: This single-centre retrospective study was carried out at Catharina Hospital in Eindhoven, The Netherlands. The MRIs of 124 infertile women undergoing their first, fresh embryo transfer during IVF/ICSI, diagnosed with adenomyosis only (N = 31), or combined adenomyosis and endometriosis (N = 93) were assessed. Measurements of MRI adenomyosis features were performed by two independent investigators. IVF/ICSI outcomes (biochemical pregnancy (BP), ongoing pregnancy (OP) and live birth (LB)) of adenomyosis patients were compared to those of 889 male infertility controls.Results: Patients with adenomyosis had significantly worse IVF/ICSI outcomes compared to male infertility controls. When assessing individual MRI parameters, adenomyosis patients with a mean junctional zone (JZ) of >12 mm, a JZ/Myometrium ratio of >40%, presence of myometrial cysts and presence of endometriosis (specifically deep invasive endometriosis(DIE)) showed statistically significantly worse outcomes compared to patients with milder disease.Conclusion: The results of this retrospective study suggest that individual MRI markers for severe adenomyosis (mean JZ > 12 mm, myometrial cysts), especially when combined with (severe) endometriosis, may be associated with fewer pregnancies during IVF/ICSI when compared to male infertility controls. Future prospective studies should investigate the prognostic potential of these markers for prediction of IVF/ICSI success.

Study Objective: Development of a prediction tool for histopathological adenomyosis diagnosis after hysterectomy based on MRI and clinical parameters. Design: Single-centre retrospective cohort study Setting: Gynaecological department of a referral hospital from 2007-2022. Population: 296 women undergoing hysterectomy with preoperative pelvic MRI Methods: MRI’s were retrospectively assessed for adenomyosis markers (junctional zone (JZ) parameters, high signal intensity foci (HSI) foci) in a blinded fashion. A multivariate regression model for histopathological adenomyosis diagnosis was developed based on MRI and clinical variables from univariate analysis with p>0.10 and factors deemed clinically relevant. Results: 131/296 women (44.3%) had histopathological adenomyosis. Patients were of comparable age at hysterectomy, BMI and clinical symptoms, p>0.05. Adenomyosis patients more often had undergone a curettage (22.1% vs. 8.9%, p=0.002), a higher mean JZ thickness (9.40 vs. 8.35mm, p <.001), maximal JZ thickness (16.00 vs. 13.40mm, p<.001), mean JZ/myometrium ratio (0.56 vs. 0.49, p=.040), and JZ differential (8.60 vs. 8.15mm, p=.003). Presence of HSI foci was a strong predictor for adenomyosis (39.7% vs. 8.9%, p<.001). Based on the parameters age and BMI, history of curettage, dysmenorrhoea, abnormal uterine bleeding (AUB), mean JZ, JZ Differential  5mm, JZ/myometrium ratio >.40, and presence of HSI Foci, a predictive model was created with a good Area Under the Curve (AUC) of .776. Conclusions: This is the first study to create a diagnostic tool based on MRI and clinical parameters for adenomyosis diagnosis. After sufficient external validation, this model could function as a useful clinical-decision making tool in women with suspected adenomyosis.

Objectives: To compare intrauterine adhesion (IUA) formation after hysteroscopic removal (HR) of retained products of conception (RPOC) with IUA formation after ultrasound-guided electric vacuum aspiration (EVA) and externally validate the outcomes of an RCT. Study design: This prospective cohort study was conducted from April 2015 until June 2022 in 2 Dutch teaching hospitals and one Belgian university hospital. Women opting for EVA underwent the procedure as soon as possible. In the HR group, the therapeutic hysteroscopy was performed at least eight weeks after the end of pregnancy. Postoperatively, an office second-look hysteroscopy was offered to all patients. Women were included if they had been diagnosed with RPOC ranging from 1 to 4 cm on ultrasound and did not want to participate in the RCT. EVA was performed using a Karman cannula. Operative hysteroscopy consisted either of hysteroscopic morcellation with the TruClearTM System or the Intrauterine BIGATTI Shaver or cold loop resection with a bi-polar resectoscope.Results: Of 178 included women, 124 were treated with HR and 28 with EVA. Outcomes of HR and EVA did not differ significantly in terms of complications (5.6 % vs 3.6 %; p = 1.00). Second-look hysteroscopy showed IUAs in 14 of 91 women (15.4 %) after HR and in 1 of 16 (6.3 %) after EVA (p = .461). Completeness of removal was significantly higher (90.1 %) after HR than after EVA (68.8 %) (p = .035). Additional operative hysteroscopy was required in 14.3 % of the HR group versus 37.5 % in the EVA group (p = .036). Conclusion: In our cohort study, no significant differences in IUAs or complications were found. RPOC removal with HR was more often complete than removal with EVA, and additional therapeutic hysteroscopy was less frequently required after HR. These findings need to be correlated with those of RCTs. Clinical trial registration: The study was registered in de Dutch Trial Register (NTR4923). Date of registration 23-11-2014. Date of first enrollment 01-01-2015. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923

Meta-analyses comparing hysteroscopic electromechanical morcellation with electrosurgical resection showed a shorter operating time for electromechanical morcellation, mainly for polypectomy. The Resectr™ 9Fr is a new hysteroscopic manual morcellator, designed to simplify this procedure. We aimed to compare manual with electromechanical morcellation for hysteroscopic polypectomy. This two-center randomized controlled non-inferiority trial was performed from 2018 to 2021 in the Catharina Hospital and the Ghent University Hospital. The study was registered at the Dutch Trial Register (NL6922; ICTRP ID: NTR7118). One hundred and forty women with polyps (between 8 and 20 mm) scheduled for hysteroscopic removal were randomized between manual (Resectr™ 9Fr) or electromechanical (TruClear™) morcellation. The primary outcome was time (instrumentation set-up, resection, and total procedure time). The non-inferiority margin for the primary outcome time was 1.3. Mean instrumentation set-up time was 10% shorter with the manual compared with the electromechanical morcellator (estimated mean ratio manual/electromechanical = 0.9; 97.5% confidence interval [CI] 0.8–1.1). Mean resection time was 30% longer with the manual compared with the motor-driven system (estimated mean ratio manual/electromechanical = 1.3; 97.5% CI 0.9–1.9). Mean total procedure time was 10% longer with the manual compared with the electromechanical morcellator (estimated mean ratio manual/electromechanical = 1.1; 95% CI 0.91–1.298). The estimated odds (electromechanical/manual) of better surgeon's safety, effective and comfort scores were, respectively, 4.5 (95% CI 0.9–22.1), 7.0 (95% CI 1.5–31.9), and 5.9 (95% CI 1.1–30.3) times higher with the motor-driven compared with the manual morcellator. Conversion rates and incomplete resection rates were comparable in both groups (manual vs electromechanical) (7.6% [4/66] vs 2.9% [2/68] and 6.1% [4/66] vs 3.0% [2/66], respectively). No intraoperative and postoperative complications were registered. The manual morcellator was non-inferior to the electromechanical morcellator for hysteroscopic polypectomy in terms of mean instrumentation set-up time and total procedure time. Results on resection time were inconclusive. Conversion and incomplete resection rates were within the range reported in the literature. Surgeon's reported rating for both devices was high, however, in favor of the motor-driven tissue removal system.

Abstract Study question What is the influence of uterine contractility of in-vitro fertilisation (IVF) patients at follicle aspiration (FA) and embryo transfer (ET) on clinical pregnancy outcomes? Summary answer At time of embryo transfer, a lower contraction frequency, and increased contraction coordination is associated with more favourable chances of ongoing pregnancy after IVF/ICSI treatment. What is known already Uterine peristalsis is the rhythmic, wave-like motion of the subendometrial layer of the uterus. Various subjective methods using visual interpretation suggest that uterine peristalsis features are different in the various stages of the menstrual cycle, and they are thought to be important for fertility and early embryo implantation. Recently, a new automated quantitative method to measure uterine contractility was validated in a small number of IVF patients to analyse uterine peristalsis on transvaginal ultrasound (TVUS) recordings with speckle-tracking. With this method a new contraction feature – coordination – can be assessed alongside frequency, direction, amplitude. Study design, size, duration This study is part of an ongoing multi-centre prospective observational cohort study investigating uterine contractility on TVUS. Our study included patients undergoing IVF/ICSI treatment with good quality TVUS recordings from 2017 to 2023. Patients received fresh ET on Day 3 or Day 5. Participants/materials, setting, methods 128 IVF/ICSI patients undergoing fresh ET were included from participating centres. Patients underwent TVUS within 1 hour prior to FA(n = 61/128), and/or within one hour before ET (n = 67/128). Uterine contraction frequency (CF), amplitude, velocity and coordination were measured by applying dedicated speckle tracking and strain analysis. The primary outcome was ongoing pregnancy (OP, viable pregnancy >10 weeks gestational age). The independent T-test and Mann-Whitney U test were applied to compare features between groups. Main results and the role of chance 39.1% of the IVF/ICSI patients (50/128) achieved ongoing pregnancy. Most patients underwent IVF/ICSI treatment due to a male factor (29.0%) or idiopathic subfertility (31.9%). Age, BMI and embryo quality were comparable for the pregnant vs. non-pregnant groups (p > 0.05 for all). CF was significantly higher during FA vs. ET (1.70±0.26 vs. 1.54±0.23,[RC(1] p < 0.001), as well as contraction velocity (0.79±0.22 vs 0.63±0.16, p < 0.001). Contraction amplitude was also lower during ET vs. FA (0.06 IQR 0.03 vs. 0.08 IQR 0.04, p < 0.001[RC(2] ). During FA, no significant differences were seen in contraction features for pregnant vs. non-pregnant groups (all p > 0.05). At ET, a lower mean CF was significantly associated with OP(1.46 ±0.18 vs. 1.57±0.19 [RC(3] contraction/min, p = 0.016), as well as presence of more coordinated uterine contractions (0.22 ±0.09 vs. 0.33±0.14, p < 0.001[RC(4] ). No significant differences were found for the features of amplitude and velocity. Limitations, reasons for caution Further validation of these results is ongoing, including expansion of the sample size. No sub-analysis has yet been done to assess the effect of additional IVF/ICSI treatment characteristics (i.e. stimulation protocol, type of subfertility) on uterine contractility and chance of pregnancy. Wider implications of the findings Uterine contractility changes its character depending on the timing of IVF treatment, with different characteristics seen at FA vs. ET. The most favourable contraction profile for ongoing pregnancy after ET seems to be uterine contractions with relatively low frequency and good coordination. These findings may support decision-making at ET. Trial registration number not applicable

Objective: To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultra-sound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications.Design: A randomized controlled, nonblinded trial.Setting: Three teaching hospitals and one university hospital from April 2015 to June 2022. Patients: A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration.Intervention: Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vac-uum aspiration was performed using an 8-or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible.Main Outcome Measures: In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs.Results: Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspi-ration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspi-ration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively).Conclusion: In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments.

A first clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for office polypectomy without any anesthesia. Women with at least one small endometrial polyp were eligible. Hysteroscopic polypectomy was performed using the Resectr™ 5fr in an office setting, without any anesthesia. One hundred and two hysteroscopic polypectomies were included in the analysis. The median installation time was 1.9 min (95% confidence interval (CI) 1.6–2.1). The median time to complete polyp removal was 1.2 min (95% CI 0.8–1.6). The median surgeon’s safety, practical, and comfort scores on a 5-point Likert scale were high (5 (5–5), 5 (4–5), and 5 (4–5), respectively). Women’s pain score was low (median 1 (0–3)), whereas the satisfaction rate was high (median 5 (5–5)), both on a 5-point Likert scale. There were two conversions (hysteroscopic scissors (n = 1), a new Resectr™ 5fr device (n = 1)). There was one incomplete procedure (tissue hardness). Hysteroscopic removal of small polyps, using the $${Resectr}^{TM}$$ 5fr in an office setting is feasible in terms of installation and resection time. Surgeon’s practical, comfort, and safety scores are high, whereas women report low pain scores and high satisfaction rates.  Dutch Clinical Trial Registry (NTR 7119, NL6923): https://www.trialregister.nl/trial/6923 . Date of registration: 27/03/2018.

Research question: To explore normal uterine contractile function across the menstrual cycle using a novel quantitative ultrasound method. Design: This multicentre prospective observational study took place in three European centres from 2014 to 2022. Uterine contraction frequency (contractions/minute), amplitude, direction (cervix-to-fundus, C2F; fundus-to-cervix; F2C), velocity and coordination were investigated. Features were extracted from transvaginal ultrasound recordings (TVUS) using speckle tracking. Premenopausal women >= 18 years of age, with normal, natural menstrual cycles were included. A normal cycle was defined as: regular (duration 28 +/- 2 days), no dysmenorrhoea, no menometrorrhagia. Four-minute TVUS were performed during the menstrual phase, mid-follicular, late follicular phase, early luteal phase and/or late luteal phase. Of the 96 recordings available from 64 women, 70 were suitable for inclusion in the analysis. Results: Contraction frequency (for the posterior wall) and velocity (for the anterior uterine wall in the F2C direction) were highest in the late follicular phase and lowest in the menstrual and late luteal phases (1.61 versus 1.31 and 1.35 contractions/min, P < 0.001 and 0.81 versus 0.67 and 0.62 mm/s, P < 0.001, respectively). No significant difference was found for contraction amplitude. Contraction coordination (simultaneous contraction of the anterior and posterior walls in the same direction) was least coordinated in the mid-follicular phase (P = 0.002). Conclusions: This is the first study to objectively measure uterine contraction features in healthy women during the natural menstrual cycle on TVUS. Likewise, it introduces contraction coordination as a specific feature of uterine peristalsis. Differences in uterine contractility across the menstrual cycle are confirmed, with highest activity seen in the late follicular phase, and lowest in the late luteal phase.