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 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?

RIGHT UP 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.