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C.O. is a 29-year-old white woman who presented with a history of infertility for several years, followed by a history of recurrent pregnancy losses.
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Her past medical and surgical histories were negative. On gynecologic history, she was remarkable in that she reported severe dysmenorrhea for several years that was relieved by nonsteroidal anti-inflammatory drugs. Her gynecologist found a low luteal phase progesterone level and treated her with 50 mg of clomiphene citrate on days 5–9 of the cycle.
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She responded well to the medication, with a subsequent conception. The pregnancy resulted in a spontaneous abortion 5 weeks later. No dilatation and curettage (D&C) was required, and the patient recovered well. She was still unable to conceive on her own and was again given clomiphene citrate therapy. Again, she conceived and had a spontaneous abortion—this time at 7 weeks' gestation. No D&C was performed.
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The patient was evaluated for recurrent pregnancy losses. Karyotype was normal for both partners. Hormonal evaluation was normal with the exception of a low midluteal phase progesterone level. Immunologic and infectious screening failed to reveal a cause for the recurrent losses. The hysterosalpingogram (HSG) demonstrated a midline filling defect.
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The patient was informed of the results and the potential for future miscarriages. The need for further evaluation and possible repair performed via a hysteroscopic or abdominal approach, together with its risks and benefits, was carefully explained to the patient. She elected to try clomiphene citrate therapy one more time and hoped to avoid surgery.
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At 8 weeks' gestation, vaginal ultrasonography (US) revealed positive fetal cardiac activity in an ovulation induced by clomiphene citrate. While still taking micronized progesterone 100 mg 3 times daily, she was referred to her gynecologist for routine obstetric care. At 12 weeks' gestation, the patient had an incomplete abortion that required a D&C. She recovered uneventfully and later returned to the office for further evaluation and treatment.
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Several months were allowed to lapse before a hysteroscopy/laparoscopy was performed, which revealed a broad-based intrauterine septum and stage I endometriosis. To evaluate the depth and width of the septum, a LaparoScan (EndoMedix, Irvine, CA) laparoscopic 7.5-Hz probe was used during the procedure. The septum was removed with a hysteroscopic resectoscope loop on a 40-W setting. After the resection, the ultrasonic probe was again used to measure the thickness of the myometrium and to verify the resection of the septum. A 30-mL 18-F Foley catheter with the distal tip resected was placed in the fundus and inflated. The patient was discharged and placed on therapy consisting of a broad-spectrum antibiotic and conjugated estrogen 2.5 mg daily.
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The new millennium saw a proliferation of imaging techniques used in medical practice. Research into the development, refinement, and application of imaging in gynecology is apparent in the literature.
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The HSG has been considered the gold standard for imaging the uterine corpus for ...