{"paper_id":"adf66d7d-be5c-47f5-947d-4ca093276ab5","body_text":"Clin. Exp. Obstet. Gynecol. 2023; 50(1): 3\nhttps://doi.org/10.31083/j.ceog5001003\nCopyright: © 2023 The Author(s). Published by IMR Press.\nThis is an open access article under the CC BY 4.0 license .\nPublisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nOriginal Research\nClinical Predictive Factors of Failure of Hysteroscopic Endometrial\nAblation: Retrospective Cohort Study at a Tertiary University Hospital\nNaser Al-Husban1,*\n , Ala’ Abukhalaf 2, Rama Nada 2, Lina Alqirem 2, Mohammad Alshrouf 2,\nHedaieh Al-Husban3\n1Obstetrics and Gynaecology Department, School of Medicine, The University of Jordan, 13046 Amman, Jordan\n2Obstetrics and Gynaecology Department, Jordan University Hospital, 11942 Amman, Jordan\n3Obstetrics and Gynaecology Department, Ibn Al-Haitham Hospital, 11194 Amman, Jordan\n*Correspondence: Husban48@yahoo.com (Naser Al-Husban)\nAcademic Editor: Michael H. Dahan\nSubmitted: 19 August 2022 Revised: 24 October 2022 Accepted: 31 October 2022 Published: 5 January 2023\nAbstract\nBackground: Endometrial ablation is a safe and effective minimally invasive surgical procedure. Despite the high success rate of\nendometrial ablation for heavy uterine bleeding management, some patients experience persistent symptoms after the procedure, ne-\ncessitating a hysterectomy. The aim of this study is to determine the pre-operative clinical predictive factors of failure of endometrial\nablation in the management of uterine bleeding. Methods: Retrospective cohort study of endometrial ablation procedures performed\nfor treating heavy uterine bleeding. Results: Ninety five patients were included in the study. The failure rate was 24.2%. There was a\nstatistically significant association between ablation failure and fluid deficit ( p = 0.002) and intra-operative blood loss ( p = 0.047). There\nwas a statistically significant moderate association between adenomyosis (p = 0.003, φ = 0.37) and failed endometrial ablation. However,\nthe age, body mass index (BMI), parity, number of miscarriages, number of cesarean sections, uterine length, endometrial thickness and\nprocedure duration had no significant association with endometrial ablation. There was no significant relationship between the uterine\nabnormalities in general and the outcome of the endometrial ablation ( p = 0.637). However, patients with combined adenomyosis and\ndysmenorrhea had a statistically significant association with outcome of the endometrial ablation ( p = 0.016, φ = 0.28) and were more\nlikely to have a failed endometrial ablation (crude odds ratio (COR) = 4.67, 95% confidence interval (CI), 1.35–16.09). Logistic regres-\nsion to adjust for related factors revealed that the adenomyosis (adjusted odds ratio (AOR) = 50.83, 95% CI, 3.64–706.75, p = 0.003)\nand fluid deficit (AOR = 1.003, 95% CI, 1.000–1.006, p = 0.044) had a higher likelihood of an unsuccessful outcome. Hysterectomy\nwas performed in 47.8% of patients who had failure of the ablation. Conclusions: Among pre-operative factors, adenomyosis, fluid\ndeficit and combined adenomyosis and dysmenorrhea were found to predict failure of hysteroscopic endometrial ablation. Clinical Trial\nRegistration: It was registered in https://www.clinicaltrials.gov database with Identifier: NCT05483348.\nKeywords: endometrial; ablation; hysteroscopic; rollerball; uterine; adenomyosis\n1. Introduction\nEndometrial ablation (EA) is a safe and efficacious\nendoscopic surgical procedure that has become a well-\nestablished alternative option in selected women with heavy\nand abnormal uterine bleeding [1]. In the United Kingdom,\nhysterectomy rates were significantly reduced over the past\n20 years due to both improved medical treatment and in-\ncreased use of EA techniques [ 2]. EA improves treatment\naccess for those women who have abnormal uterine bleed-\ning (AUB) and provides an alternative to radical procedures\nsuch as hysterectomy [ 3]. Hysterectomy was found to be\nassociated with a higher risk than endometrial ablation of\nsurgery for pelvic floor repair and stress urinary inconti-\nnence [3].\nDespite the high success rate of endometrial ablation\nfor uterine bleeding management, some patients experi-\nence persistent symptoms after the procedure, necessitat-\ning a hysterectomy. The characteristics of patients whose\nendometrial ablation fails had been studied by Kristin A Ri-\nley in a cohort study of 51 patients who had multiple vari-\nants assessed, including age, body mass index (BMI), parity\nand tubal ligation. The only statistically significant vari-\nant was age; it also revealed that endometriosis was the\nmost common finding among patients who presented for\nhysterectomy after endometrial ablation; other findings in-\ncluded adenomyosis and leiomyomata [ 4]. Another retro-\nspective cohort study of 968 women who had endometrial\nablation between January 2007 and July 2009 compared the\nrisk of treatment failure between women who had regular\nand irregular heavy uterine bleeding, concluding that pre-\noperative bleeding pattern has no effect on failure rates or\nthe need for gynecological procedures after endometrial ab-\nlation [5]. A study that included 128 women who had en-\ndometrial ablation or resection was conducted to determine\nthe perioperative factors that influenced the success of this\nhysteroscopic intervention It was found that the presence of\nsubmucosal myoma was found to increase the risk of sub-\nsequent surgery [6].\n\nThe first-generation hysteroscopic techniques namely,\nroller ball ablation, bipolar endometrial resection and laser\nablation, all required visualization of the cavity for the en-\ntirety of the procedure [ 7]. Second generation techniques\nhave been developed which do not require hysteroscopy\nand can be easily performed without requiring high lev-\nels of skill include bipolar radiofrequency, microwave and\nthermal balloon ablation, endometrial cryotherapy, and hy-\ndrothermal ablation [8].\nThe success of endometrial ablation was seen in\n80.6% of cases [ 9]. On the other hand, failure rates of en-\ndometrial ablation, which were manifested as persistence\nof pain or bleeding, have reached 10–20% that required pa-\ntients to undergo further interventions to handle their mal-\nady [10].\nThe objective of our study was to determine additional\npatient characteristics and the clinical predictive factors of\nfailure of endometrial ablation and the need of subsequent\ngynecological procedure.\nThe primary outcomes were to determine the pre-\noperative clinical predictive factors of failure of endome-\ntrial ablation in the management of uterine bleeding. Sec-\nondary outcomes were to search for any intra-operative pre-\ndictive factors of failure of the procedure. Better under-\nstanding of the predictive factors of success or failure will\nhelp in proper counselling of patients and in decreasing the\nincidence of endometrial ablation failure and avoid further\nre-ablation or hysterectomy.\n2. Methods\n2.1 Study Design\nA retrospective cohort study was conducted in a single\ntertiary center, Jordan University Hospital (JUH). Such a\ndesign enabled us to compare two populations of similar\nbaseline characteristics for the exception of the one studied.\n2.2 Population\nPatients with heavy menstrual bleeding for 6 months\nwho had trans-cervical hysteroscopic endometrial ablation\nin the period September 2016 to September 2021 and fol-\nlowed up for at least one year. Heavy bleeding was sub-\njectively indicated by the patient as having prolonged cy-\ncles, using excessive pads, staining her underwear, affect-\ning her usual activities, taking supplements to correct her\nlow hemoglobin and the presence of clots. This bleeding\npattern should be experienced by the patient for at least 3\nmonths. Patients with hemoglobin of less than 10.5 g/dL\nwere considered anemic.\n2.3 Data Collection\nClinical data included age, BMI, parity, tubal liga-\ntion, uterine size/length (in weeks as determined by biman-\nual examination and uterine sound), endometrial thickness\n(in millimeters as measured by transvaginal ultrasound scan\n(U/S)), procedure duration, fluid deficits, presence of uter-\nine abnormality as endometriosis, adenomyosis, leiomy-\nomata and polyps or history of dysmenorrhea, menorrha-\ngia, number of cesarean sections, history of uterine surgery;\nmyomectomy, dilatation and curettage (D&C).\nPatients who had resection or subsequently had a diag-\nnosis of endometrial cancer or hyperplasia (both simple and\nthose with atypia), those with intramural fibroids, patients\nwith submucosal fibroids larger than 5 cm, patients with\nprevious ablation, patients who had ablation using bipolar\ndiathermy and those with incomplete or missing records or\nfollow up were excluded from the study’s target population.\n2.4 Ethical Considerations\nPatients’ data was treated with the utmost of confi-\ndentiality. Moreover, all records were accessed through\nJUH’s computers and under JUH’s medical staff supervi-\nsion ensuring that no data was copied or transferred to pri-\nvate storage sources. Any and all data that contributes to\nthe recognition of patients’ identities, such as names, phone\nnumbers or addresses were either turned into codes or not\nbe used at all. The study obtained approval of the insti-\ntutional review board (IRB) committee at JUH (decision\nnumber 58/2022, dated 17/02/2022). It was also registered\nin https://www.clinicaltrials.gov database with Identifier:\nNCT05483348.\nAll women had general and gynecologic examination\npreoperatively and either had diagnostic hysteroscopy or\ntrans-vaginal ultrasound (U/S) scan done by consultant gy-\nnecologists to accurately measure the uterine size, endome-\ntrial thickness and the size of the fibroids or polyps, or both\nbefore the hysteroscopic ablation.\nA written informed consent was obtained from all pa-\ntients included in this study. The consent included full\nexplanation of the procedure, benefits, potential complica-\ntions and risks.\n2.5 Surgical Technique\nHysteroscopic ablation was performed in the post-\nmenstrual period when the endometrium was very thin. In\nour practice, we not use pre-operative endometrial thin-\nning agents. The operative hysteroscopy in our study was\ndone using rigid, with 30 degrees angulated continuous\nflow hysteroscopy utilizing a monopolar rollerball. This\nnecessitated the use of glycine 1.5% as a uterine distending\nmedium in 3.0 Liter-bags. The monopolar resectoscope was\nsterilizable and reusable while the bipolar one was a single-\nuse instrument, thus minimizing financial costs. The flow\nrate used was at 250 mL/minute. Myomectomy cases were\nperformed using angled wire cutting loop electrodes. All\npatients had standardized 80 millimeter mercury (mmHg)\nof intra-uterine pressure during surgery with the use of the\nsame automated glycine infusion pump. Patients had cervi-\ncal dilatation done to 10 mm using Hegar dilators unless the\ncervix was already found to be dilated. Patients with uterine\npolyps or fibroids (submucosal (SM) type 0 and 1 only) [11]\n2\n\n\nTable 1. Comparison of failed and successful endometrial ablations in relation to different factors.\nV ariables Failure Success p value Effect size\nMean Standard deviation Mean Standard deviation\nAge 45.39 8.45 46.36 6.68 0.431 -\nBMI 30.75 3.47 29.8 6.71 0.413 -\nParity 4.1 2.49 4.43 2.27 0.283 -\nMiscarriage 0.81 0.87 1.23 1.6 0.51 -\nN of cesarean sections 2 1.66 1.31 1.55 0.135 -\nUterine length (weeks) 9.57 2.48 8.59 1.91 0.057 -\nEndometrial thickness (mm) 10.77 5.21 11.02 7.04 0.935 -\nProcedure duration (min) 36.3 14.94 35.42 13.63 0.893 -\nFluid deficit (cc) 575 298.33 335.3 203.99 0.002 0.34\nBlood loss (cc) 65.22 49.35 49.93 46.09 0.047 0.21\nNotes: p values for the Parity and uterine length were calculated by independent sample t-test. All other items were\nsubjected to Mann-Whitney Utest or Mann–Whitney–Wilcoxon (MWW/MWU) test. BMI, body mass index; mm,\nmillimeter; min, minute; cc, cubic centimeter; N, number.\nhad their lesions first resected using a resectoscope loop fol-\nlowed by rollerball endometrial ablation (REA). Before the\nREA, all patients had curettage of the whole endometrial\ncavity to obtain tissue for histopathological examination\nand to thin the endometrial to enhance the thermal effect\nof the ablation. There were selected cases that had bipo-\nlar ablation and they were excluded from the study to have\na homogenous study population. All procedures were per-\nformed by the same consultant gynecologist. Data was ex-\ntracted from patients’ clinical notes in the clinic, operative\nnotes, admission and follow up visits’ notes.\nData was extracted by using relevant International\nClassification of Diseases—Ninth revision (ICD-9) codes\nas well as Current Procedural Terminology (CPT) codes\n[12].\nPatients included in this study experienced heavy uter-\nine bleeding and underwent endometrial ablation. Success-\nful cases were defined as patients’ satisfaction with the pro-\ncedure as indicated by amenorrhea or very light menstrual\nbleeding for 12 months at least. Failure was defined as\npatients’ un-satisfaction necessitating subsequent gyneco-\nlogical procedures such as hysterectomy or repeat ablation\nwithin 12 months after the endometrial ablation. We did\nnot assess the effect of the ablation on the post-operative\nhemoglobin level. We then determined those who were\nunsatisfied (recurrent heavy bleeding, dysmenorrhea) and\nthose who ended up with repeated ablation, hormonal treat-\nment and those who had hysterectomy after the ablation.\n2.6 Statistical Analysis\nData analysis was performed using the IBM SPSS,\nversion 28.0 (IBM Corp., Armonk, NY , USA) developed\nby Norman H. Nie, Dale H. Bent and C. Hadlai Hull. Cate-\ngorical variables were summarized as frequencies and per-\ncentages. Participants were categorized into two groups ac-\ncording to their failure or success of the primary endome-\ntrial ablation. Pearson’s Chi-square ( χ2) test and Fischer’s\nexact test with crude odds ratios (COR) (95% confidence in-\nterval (CI)) was used to determine the association between\ncategorical data. The phi coefficient ( φ) was used as a mea-\nsure of the strength of association.\nNormality was assessed using the Shapiro-Wilk test.\nIndependent samples t-test and Mann-Whitney U tests were\nused to determine the association between continuous data.\nThe effect size was calculated depending on the test use by\neffect size r for Mann-Whitney U. V ariables that showed\npotentially interesting associations from the univariate anal-\nysis were included in the binary logistic regression model\nin order to control for possible confounding factors, which\nwere summarized using adjusted odds ratios (AOR) (95%\nCI). Statistical significance was defined as a p-value of less\nthan 0.05.\n3. Results\nIn total, there were 138 procedures were done in the\nstudy period. Ninety-five patients were included in this\nstudy; the age ranged from 29 to 52 years, with a mean age\nof 46.13 ± 7.11 years. Among the participants, the mean\nBMI was 29.97 ± 6.23, ranged from 18 to 56. Participants\nwere categorized into two groups according to their fail-\nure or success of the primary endometrial ablation. Overall,\n24.2% (n = 23) had a failed endometrial ablation with a sub-\nsequent gynecological procedure and 75.8% (n = 72) had a\nsuccessful endometrial ablation with no further procedures\nrequired. Tables 1,2 show a comparison between patients\nwith successful and those with failed endometrial ablation\ngroups.\nOur results showed a significant difference between\npatients with successful and failed endometrial ablations in\nregard to fluid deficit ( p = 0.002) and blood loss during the\nsurgery ( p = 0.047); however, the age, BMI, parity, num-\nber of miscarriages, number of cesarean sections, uterine\nlength, endometrial thickness and procedure duration had\nno significant difference between the two groups (p > 0.05).\n3\n\nTable 2. A comparison between the clinical characteristics of failed and successful endometrial ablation.\nV ariables Total number (%) Endometrial ablation OR (95% CI) p value\nFailure Success\nSmoker (yes) 3/78 (3.8) 2/18 (11.1) 1/60 (1.7) 7.38 (0.63–86.60) 0.131\nHistory of coagulation disorders (yes) 1/92 (1.1) 0/22 (0) 1/70 (1.4) 0.99 (0.96–1.01) 1\nUse of anticoagulants (yes) 1/92 (1.1) 0/22 (0) 1/70 (1.4) 0.99 (0.96–1.01) 1\nPrevious tubal ligation (yes) 9/95 (9.5) 2/23 (8.7) 7/72 (9.7) 0.88 (0.17–4.59) 1\nUterine abnormalities 1.55 (0.26–9.16) 0.637\nPolyps 43/84 (51.2) 7/21 (33.3) 36/63 (57.1)\nFibroids 42/84 (50) 14/21 (66.7) 28/63 (44.4)\nAdenomyosis 6/84 (7.1) 5/21 (23.8) 1/63 (1.6)\nNo abnormalities 6/84 (7.1) 2/21 (9.5) 4/63 (6.3)\nEndometriosis 3/84 (3.6) 0/21 (0) 3/63 (4.8)\nThickened endometrium 3/84 (3.6) 0/21 (0) 3/63 (4.8)\nLeiomyomata 1/84 (1.2) 1/21 (4.8) 0/63 (0)\nMenstrual abnormalities 0.38 (0.08–1.83) 0.349\nMenorrhagia 79/89 (88.8) 18/21 (85.7) 61/68 (89.7)\nDysmenorrhea 7/89 (7.9) 2/21 (9.5) 5/68 (7.4)\nIntermenstrual spotting 1/89 (1.1) 0/21 (0) 1/68 (1.5)\nHistory of uterine surgery 0.66 (0.23–1.90) 0.440\nDilation and curettage 51/91 (56) 15/22 (68.2) 36/69 (52.2)\nEvacuations 7/91 (7.7) 0/22 (0) 7/69 (10.1)\nMyomectomy 4/91 (4.4) 0/22 (0) 4/69 (5.8)\nOther 7/91 (7.7) 0/22 (0) 7/69 (10.1)\nNo 31/91 (34.1) 6/22 (27.3) 25/69 (36.2)\nIndication for primary endometrial ablation\nMenorrhagia 36/95 (37.9) 12/23 (52.2) 24/72 (33.3) 2.18 (0.84–5.66) 0.139\nHeavy menstrual bleeding 31/95 (32.6) 4/23 (17.4) 27/72 (37.5) 0.35 (0.11–1.14) 0.081\nFibroid 17/95 (17.9) 8/23 (34.8) 9/72 (12.5) 3.73 (1.24–11.29) 0.026\nIrregular vaginal bleeding 14/95 (14.7) 2/23 (8.7) 12/72 (16.7) 0.48 (0.10–2.30) 0.506\nPolyps 10/95 (10.5) 0/23 (0) 10/72 (13.9) – 0.112\nPostmenopausal bleeding 9/95 (9.5) 2/23 (8.7) 7/72 (9.7) 0.88 (0.17–4.59) 1\nInfertility 3/95 (3.2) 1/23 (4.3) 2/72 (2.8) 1.59 (0.14–18.40) 0.569\nThere might be more than one indication. OR, odds ratio; CI, confidence interval.\nTable 1 shows the details of the successful and failed en-\ndometrial ablations.\nThere was no significant relationship between the\nuterine abnormalities in general and the outcome of the en-\ndometrial ablation ( p = 0.637); however, there was a sta-\ntistically significant, moderate association between adeno-\nmyosis and the outcome of the endometrial ablation ( p =\n0.003, φ = 0.37) and were more likely to have a failed\nendometrial ablation COR = 19.38, 95% CI, 2.11–177.73)\n(Table 2). In addition, patients with combined adenomyosis\nand dysmenorrhea had a statistically significant association\nwith the outcome of the endometrial ablation ( p = 0.016, φ\n= 0.28) and were more likely to have a failed endometrial\nablation (COR = 4.67, 95% CI, 1.35–16.09).\nMenorrhagia and heavy irregular menstrual bleeding\nwere among the most common indications for endometrial\nablation in 37.9% and 32.6% of the patients, respectively.\nMoreover, the patients who underwent endometrial ablation\ndue to fibroids (17.9%) had a significant weak relationship\nwith the outcome of the endometrial ablation ( p = 0.26, φ\n= 0.25), they were more likely to have a failed endometrial\nablation (COR = 3.73, 95% CI, 1.24–11.29). Other indi-\ncations included irregular vaginal bleeding, polyps, post-\nmenopausal bleeding, and infertility and they no longer\nsought pregnancy and would only treat their heavy periods.\nWe also found that patients who had both adenomyosis\nand dysmenorrhea were at higher statistically significant\nrisk to have ablation failure than those with adenomyosis\nalone, p value = 0.016, 95% CI, 1.51–50.69 and p value=\n0.003, φ = 0.37, respectively.\nOverall, 24.2% had a failed endometrial ablation and\nhad to undergo an additional procedure to alleviate the\nsymptoms. The most common were repeated hysteroscopic\nablation and hysterectomy, in 15 and 11 patients, respec-\ntively (Table 3).\nIn order to account for any confounding effects, the\nvariables having significant associations at the p < 0.1 level\nfrom the univariate analysis were included in the logistic\n4\n\n\nTable 3. Subsequent gynecological procedures after failed\nablation (N = 23).\nSurgeries N (%)\nHysterectomy 11 (47.8)\nHysteroscopy and repeated ablation 15 (65.2)\nDilation and curettage (endometrial biopsy) 9 (39.1)\nOther 5 (21.7)\nSome patients underwent more than one procedure. N, number.\nregression model. These were the uterine length in weeks,\nfluid deficit, blood loss, diagnosis of adenomyosis, heavy\nmenstrual bleeding and fibroid(s). The significant pre-\ndictors for endometrial ablation failure were adenomyosis\n(AOR = 50.83, 95% CI, 3.64–706.75, p = 0.003) and fluid\ndeficit (AOR = 1.003, 95% CI, 1.000–1.006, p = 0.044).\nThe uterine length in weeks, blood loss, indication for pri-\nmary endometrial ablation being heavy menstrual bleed-\ning, or presence of fibroid were not significant predictors\nin the regression model, which had a Pseudo Nagelkerke R\nSquared of 0.49. Table 4 demonstrates the regression model\nresults for an endometrial ablation failure prediction.\nTable 4. The results of regression model for endometrial\nablation failure.\nV ariables AOR 95% CI p value\nUterine length (weeks) 1.069 0.704–1.622 0.755\nFluid deficit (mL/cc) 1.003 1.000–1.006 0.044\nBlood loss (mL/cc) 1.004 0.991–1.018 0.505\nAdenomyosis 50.825 3.655–706.745 0.003\nHeavy menstrual bleeding 0.295 0.043–2.015 0.213\nFibroid 3.224 0.585–17.754 0.179\nAOR, adjusted odds ratios; CI, confidence interval; mL, milliliter;\ncc, cubic centimeter.\n4. Discussion\nThe overall success rate of our endometrial ablation\nprocedures using the firstly generation rollerball ablative\ntechnique, REA, was very much good, acceptable and very\nhelpful in a third world country with limited resources.\nWhen compared with hysterectomy, the treatment of AUB\nwith endometrial ablation has been associated with reduced\noperative time, decreased morbidity, and cost effectiveness\n[13,14].\nOver half of patients treated with microwave endome-\ntrial ablation (MEA) achieved amenorrhea, and the proce-\ndure was suitable for women with myomas and irregular\nuterine cavities and the success rate of MEA at 12 months\n(87.0%; 95% CI, 81.7%–91.2%) did not differ significantly\n(p = 0.40) from that of REA (83.2%; 95% CI, 74.7%–\n89.7%) [15].\nOur study showed an overall failure rate of 24.2%. All\npatients were operated upon using either general or spinal\nanesthesia with no reported serious complications like per-\nforation, bleeding or significant fluid absorption. When\nsecond-generation versus first-generation techniques were\ncompared, there was no evidence of differences in amen-\norrhea at 1 year and 2 to 5 years’ follow-up and there was\nsubjective improvement at 1 year follow-up based on a Pic-\ntorial Blood Assessment Chart (PBAC) [ 16]. Moreover,\npatient satisfaction was not different between second- and\nfirst-generation techniques at 1 year, 2 years and 5 years’\nfollow-up. Second-generation ablation techniques were as-\nsociated with shorter operating times and more often were\nperformed under local instead of general anaesthesia [ 16].\nThere was uncertainty whether perforation rates differed\nbetween second- and first-generation techniques [ 16]. Tri-\nals reported little or no difference between second- and first-\ngeneration techniques in requirement for additional surgery\n(ablation or hysterectomy) at 1 and 5 years’ follow-up [ 16].\nThese findings support our practice in using first genera-\ntion ablation as newer generations (second and third) are\nexpensive and not readily available in our country. Simi-\nlarly, levonorgestrel intra-uterine system (LNG-IUS) is still\nexpensive in Jordan and not covered by many medical in-\nsurance companies. In a meta-analysis in 2020, endome-\ntrial ablation and LNG-IUS were found to be two excellent\ntreatment options for heavy menstrual bleeding, although\nwomen treated with the LNG-IUS were at higher risk of\nexperiencing side effects compared to women treated with\nendometrial ablation/resection [17]. This is very encourag-\ning to us to further implement endometrial ablation in our\npractice taking into consideration the global and, particu-\nlarly, the local economic restrictions. Similarly, in a re-\nview, when compared to endometrial ablation, it was not\nclear whether the LNG IUS offered any benefits with re-\ngard to reduced heavy bleeding while satisfaction rates and\nquality of life measures were found to be similar. In the\nsame review, some minor adverse effects were more com-\nmon with the LNG IUS but it appeared to be more cost\neffective than endometrial ablation techniques [ 18]. Hys-\nterectomy was found to cause serious complications for a\nminority of women and most women might be well advised\nto try a less radical treatment as first-line therapy and it was\nfound that both LNG-IUS and conservative surgery (abla-\ntion/resection) appeared to be safe, acceptable and effective\n[19]. Unfortunately, there were no studies in Jordan that\ncompared these different modalities regarding particularly\ncost-effectiveness and patient satisfaction. There is an on-\ngoing a multicenter randomized controlled trial to evaluate\nif the combination of endometrial ablation and an LNG-IUS\nis superior to endometrial ablation alone in terms of reduc-\ning subsequent rates of hysterectomy at two years following\nthe initial ablative procedure [ 20].\nOur study found a significant association between\ngreater operative blood loss and fluid absorption (fluid\ndeficit), as independent factors, with endometrial ablation\n5\n\nfailure. The presence of adenomyosis and uterine fibroids\nas indication of endometrial ablation was also found to\nbe significantly associated with the outcome of the en-\ndometrial ablations. However, the patient’s age, BMI, par-\nity, miscarriage, previous cesarean sections, uterine length\n(in weeks), endometrial thickness (in millimeters mm),\ndysmenorrhea and procedure duration (minutes) were not\nfound to influence the effectiveness of the procedure. Some\nbut not all of these findings were consistent with previous\nstudies. Previous Cesarean delivery was not associated with\nan increased risk of failure of endometrial ablation, but dys-\nmenorrhea, a submucous myoma and longer uterine depth\nare [21]. Their definition of failure was those patients who\nhad ablation and hysterectomy. In our study, we did not\nspecify hysterectomy as the only destination for failure def-\ninition. Moreover, dysmenorrhea cases in our study were\nonly seven in both failed and successful cases. This low\nnumber might have influenced the statistical result.\nWe had a total of 6 cases of adenomyosis who had ab-\nlation; one was successful while the remaining 5 were a fail-\nure. There was no statistically significant difference in the\noutcome in our study concerning the success or failure of\nablation. This might be due to the low number of cases\nor to the degree of junctional zone changes. In fact, the\neffect of transcervical endometrial resection might depend\nupon the degree of junctional zone changes, and patients\nwith intrinsic adenomyosis were more likely to undergo re-\nintervention surgery than patients with either linear or ser-\nrated junctional zone [ 22]. However, hysteroscopic roller-\nball endometrial ablation as a surgical management in pa-\ntients with adenomyosis associated with menorrhagia was\nfound to be an effective and safe procedure which could\nreduce the need for the unnecessary major surgery of hys-\nterectomy [23].\nIn a systemic review and meta-analysis [ 10], younger\nage, prior tubal ligation and preexisting dysmenorrhea were\nfound to be associated with failure of endometrial ablation.\nObesity and large submucous fibroids showed conflicting\nresults and there was a need for further research to estimate\nthe influence of these factors. This meta-analysis involved\nstudies that were different from ours. The studies involved\nin this meta-analysis were using second generation endome-\ntrial ablation [10].\nOur study did not show a statistically significant dif-\nference in ablation failure or success regarding preoperative\nmenstrual irregularities and intermenstrual spotting. These\nfindings were similar to a retrospective cohort study of a\nrelatively large number of patients (968) [ 5].\nAs the first- and second- generation ablation tech-\nniques are effective and safe, we can expand our hystero-\nscopic endometrial ablation service to decrease the need\nfor hysterectomy and particularly useful for patients with\ncontraindications for medical therapy [ 24]. Both seem to\nbe equally effective in reducing heavy bleeding and there\nwas no evidence that rates of satisfaction differed signif-\nicantly [ 25]. Despite second-generation techniques were\noften found to be easier to perform with shorter operative\ntimes with the ability to use local rather than general anes-\nthesia and complications appeared to be less after second-\ngeneration techniques, the easiness of use can be a pitfall\n[25]. In fact, our experience with the first-generation tech-\nnique showed that in expert hands and with strict adherence\nto energy settings and fluid management, significant com-\nplications could almost be eliminated.\nEndometrial resection and ablation were effective al-\nternative to hysterectomy for heavy menstrual bleeding and\nboth were shown to have high satisfaction rates. Hysterec-\ntomy was associated with longer operating time, longer re-\ncovery period and higher rates of postoperative complica-\ntions [26]. These features further support the incorporation\nof endometrial ablation service particularly in developing\nand under-resourced countries with limited financial, tech-\nnical and medical capabilities to deal with complications.\nIn our practice, for endometrial ablation, we use the\nmonopolar rollerball rather than the resectoscope. For bipo-\nlar resectoscope, in a randomized clinical trial, no sig-\nnificant difference was found in the postoperative PBAC\nscore, amenorrhea rates, patient satisfaction, and need for\nre-intervention between ball endometrial ablation and trans-\ncervical resection of the endometrium using resectoscope\n[27]. This might have further explained the success and\nlow complication rates in our study.\nWe did not assess post-ablation pain in our study as we\nfollowed patients for one year. It was reported in 20.8% of\ncases and the median number of days for the development\nof pain after ablation was 301 days [ 28].\nThe strengths of our study lied in the consistency of\nthe study population and of the surgical technique. More-\nover, the low cost of the procedure was a feature as no pre-\noperative thinning agents were used and, instead, whole en-\ndometrial cavity curettage was utilized to obtain tissue for\nassessment and to mechanically and instantly thin the en-\ndometrium to increase the effectiveness of the thermal dam-\nage on the endometrium.\nStudy Limitations\nThe study was limited by its retrospective nature and\nbeing a single-center study. The post-operative follow up\nwas another limiting feature.\n5. Conclusions\nAmong pre-operative factors, adenomyosis, fluid\ndeficit and combined adenomyosis and dysmenorrhea were\nfound to predict failure of hysteroscopic endometrial abla-\ntion.\nAbbreviations\nBMI, body mass index; EA, endometrial ablation;\nAUB, abnormal uterine bleeding; JUH, Jordan university\nhospital; g, gram; mL, milliliter; dL, deciliter; D&C, dilata-\n6\n\n\ntion and curettage; IRB, institutional review board; U/S, ul-\ntrasound; mmHg, millimeter mercury; REA, rollerball en-\ndometrial ablation; ICD, international classification of dis-\neases; CPT, current procedural terminology; COR, crude\nodds ratio; AOR, adjusted odds ratio; CI, confidence in-\nterval; mm, millimeter; min, minute; cc, cubic centime-\nter; MEA, microwave endometrial ablation; PBAC, picto-\nrial blood assessment chart; LNG-IUS, levonorgestrel intra-\nuterine system; SM, submucosal.\nAvailability of Data and Materials\nAll data are available from the corresponding author\non reasonable request.\nAuthor Contributions\nNA—design, concept and writing the manuscript;\nAA—statistical analysis and extraction of data; RN—\nstatistical analysis and extraction of data; LA—statistical\nanalysis and extraction of data; MA—statistical analysis\nand extraction of data; HA—drafting and revision. All au-\nthors read and approved the final manuscript.\nEthics Approval and Consent to Participate\nThe study was conducted in accordance with the Dec-\nlaration of Helsinki, and the protocol was approved by the\nEthics Committee of Jordan University hospital decision\nnumber 58/2022, dated 17/02/2022.\nAcknowledgment\nNot applicable.\nFunding\nThis research received no external funding.\nConflict of Interest\nThe authors declare no conflict of interest.\nReferences\n[1] Laberge P , Leyland N, Murji A, Fortin C, Martyn P , Vilos G, et\nal. Endometrial Ablation in the Management of Abnormal Uter-\nine Bleeding. Journal of Obstetrics and Gynaecology Canada.\n2015; 37: 362–376.\n[2] Reid PC. Endometrial ablation in England–coming of age?\nAn examination of hospital episode statistics 1989/1990 to\n2004/2005. European Journal of Obstetrics and Gynecology and\nReproductive Biology. 2007; 135: 191–194.\n[3] Cooper K, Lee A, Chien P , Raja E, Timmaraju V , Bhattacharya\nS. Outcomes following hysterectomy or endometrial ablation\nfor heavy menstrual bleeding: retrospective analysis of hospital\nepisode statistics in Scotland. BJOG: An International Journal\nof Obstetrics & Gynaecology. 2011; 118: 1171–1179.\n[4] Riley KA, Davies MF, Harkins GJ. Characteristics of Patients\nUndergoing Hysterectomy for Failed Endometrial Ablation.\nJournal of the Society of Laparoendoscopic Surgeons. 2013; 17:\n503–507.\n[5] Smithling KR, Savella G, Raker CA, Matteson KA. Preoper-\native uterine bleeding pattern and risk of endometrial ablation\nfailure. American Journal of Obstetrics and Gynecology. 2014;\n211: 556.e1–556.e6.\n[6] Gemer O, Kruchkovich J, Huerta M, Kapustian V , Kroll D,\nAnteby E. Perioperative predictors of successful hysteroscopic\nendometrial ablation. Gynecologic and Obstetric Investigation.\n2007; 63:205–208.\n[7] Papadopoulos NP , Magos A. First-generation endometrial abla-\ntion: roller-ball vs loop vs laser. Best Practice & Research Clin-\nical Obstetrics & Gynaecology. 2007; 21: 915–929.\n[8] Madhu CK, Nattey J, Naeem T. Second generation endometrial\nablation techniques: an audit of clinical practice. Archives of\nGynecology and Obstetrics. 2009; 280: 599–602.\n[9] Takahashi WH, Lopes RG, Depes Dde B, Martins e Castello\nBranco HK. Results of hysteroscopic endometrial ablation after\nfive-year follow-up. Revista Brasileira de Ginecologia e Obste-\ntricia. 2012; 34: 80–85. (In Portuguese)\n[10] Beelen P , Reinders IMA, Scheepers WFW, Herman MC, Ge-\nomini PMAJ, van Kuijk SMJ, et al . Prognostic Factors for\nthe Failure of Endometrial Ablation. Obstetrics & Gynecology.\n2019; 134: 1269–1281.\n[11] Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO classi-\nfication system (PALM-COEIN) for causes of abnormal uterine\nbleeding in nongravid women of reproductive age. International\nJournal of Gynecology and Obstetrics. 2011; 113: 3–13.\n[12] National Center for Health Statistics. International Classifica-\ntion of Diseases, Ninth Revision, Clinical Modification (ICD-\n9-CM). 2021. Available at: https://www.cdc.gov/nchs/icd/icd9c\nm.htm (Accessed: 20 October 2022).\n[13] Bonafede MM, Miller JD, Lukes A, Meyer NM, Lenhart GM.\nComparison of direct and indirect costs of abnormal uter-\nine bleeding treatment with global endometrial ablation and\nhysterectomy. Journal of Comparative Effectiveness Research.\n2015; 4: 115–122.\n[14] Dwyer N, Hutton J, Stirrat GM. Randomised controlled trial\ncomparing endometrial resection with abdominal hysterectomy\nfor the surgical treatment of menorrhagia. BJOG: An Interna-\ntional Journal of Obstetrics and Gynaecology. 1993; 100: 237–\n243.\n[15] Cooper JM, Anderson TL, Fortin CA, Jack SA, Plentl MB. Mi-\ncrowave Endometrial Ablation vs. Rollerball Electroablation for\nMenorrhagia: a Multicenter Randomized Trial. The Journal of\nthe American Association of Gynecologic Laparoscopists. 2004;\n11: 394–403.\n[16] Bofill Rodriguez M, Lethaby A, Grigore M, Brown J, Hickey\nM, Farquhar C. Endometrial resection and ablation techniques\nfor heavy menstrual bleeding. The Cochrane Database of Sys-\ntematic Reviews. 2019; 1: CD001501.\n[17] Bergeron C, Laberge PY , Boutin A, Thériault M, V alcourt F,\nLemyre M, et al. Endometrial ablation or resection versus lev-\nonorgestrel intra-uterine system for the treatment of women with\nheavy menstrual bleeding and a normal uterine cavity: a system-\natic review with meta-analysis. Human Reproduction Update.\n2020; 26: 302–311.\n[18] Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or\nprogestogen-releasing intrauterine systems for heavy menstrual\nbleeding. The Cochrane Database of Systematic Reviews. 2015;\n4: CD002126.\n[19] Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical\ntherapy for heavy menstrual bleeding. The Cochrane Database\nof Systematic Reviews. 2003; CD003855.\n[20] Oderkerk TJ, Beelen P , Geomini PMAJ, Herman MC, Lee-\nmans JC, Duijnhoven RG, et al. Endometrial ablation plus lev-\nonorgestrel releasing intrauterine system versus endometrial ab-\nlation alone in women with heavy menstrual bleeding: study\nprotocol of a multicentre randomised controlled trial; MIRA2\ntrial. BMC Women’s Health. 2022; 22: 257.\n7\n\n[21] Peeters JAH, Penninx JPM, Mol BW, Bongers MY . Prognostic\nfactors for the success of endometrial ablation in the treatment of\nmenorrhagia with special reference to previous cesarean section.\nEuropean Journal of Obstetrics & Gynecology and Reproductive\nBiology. 2013; 167: 100–103.\n[22] Rasmussen CK, Hansen ES, Al-Mashadi Dahl S, Ernst E, Due-\nholm M. The effect of transcervical endometrial resection on\nclinical symptoms related to intrinsic adenomyosis and junc-\ntional zone changes. European Journal of Obstetrics & Gyne-\ncology and Reproductive Biology: X. 2019; 3: 100029.\n[23] Preutthipan S, Herabutya Y . Hysteroscopic rollerball endome-\ntrial ablation as an alternative treatment for adenomyosis with\nmenorrhagia and/or dysmenorrhea. The Journal of Obstetrics\nand Gynaecology Research. 2010; 36: 1031–1036.\n[24] Hokenstad AN, El-Nashar SA, Khan Z, Hopkins MR, Famuyide\nAO. Endometrial Ablation in Women with Abnormal Uterine\nBleeding Related to Ovulatory Dysfunction: a Cohort Study.\nJournal of Minimally Invasive Gynecology. 2015; 22: 1225–\n1230.\n[25] Bongers MY . Hysteroscopy and heavy menstrual bleeding (to\ncover TCRE and second-generation endometrial ablation). Best\nPractice & Research Clinical Obstetrics & Gynaecology. 2015;\n29: 930–939.\n[26] Fergusson RJ, Lethaby A, Shepperd S, Farquhar C. Endometrial\nresection and ablation versus hysterectomy for heavy menstrual\nbleeding. The Cochrane Database of Systematic Reviews. 2013;\n29: CD000329.\n[27] Subbaiah M, Selvest N, Maurya D. Comparison of bipolar\nball endometrial ablation and transcervical resection of the en-\ndometrium in the treatment of heavy menstrual bleeding: a\nrandomized clinical trial. Gynecology and Minimally Invasive\nTherapy. 2021; 10: 143.\n[28] Thomassee MS, Curlin H, Y unker A, Anderson TL. Predicting\npelvic pain after endometrial ablation: which preoperative pa-\ntient characteristics are associated? Journal of Minimally Inva-\nsive Gynecology. 2013; 20: 642–647.\n8","source_license":"CC0","license_restricted":false}