Postablation–tubal sterilization syndrome following thermal balloon endometrial ablation

A 45-year-old woman, gravida 4, para 2, had a 4-year history of menorrhagia associated with iron deficiency anemia, which could not be controlled with medical treatment. Outpatient diagnostic hysteroscopy showed a normal uterine cavity and the endometrial biopsy revealed secretory endometrium. She had had two uncomplicated vaginal deliveries and two first-trimester abortions and had undergone laparoscopic tubal ligation 18 years ago. She was treated with a dose of gona-dotropin-releasing hormone analog, subcutaneous Triptorelin (Decapeptyl) 3.75 mg, for endometrial priming and underwent endometrial ablation using the ThermaChoice™ uterine balloon therapy system (Gynecare, Ethicon Inc, USA). The patient remained amenorrheic in the first 3 months after the ablation and then her period returned, which was light but associated with severe lower abdominal pain requiring intramuscular analgesic injection. At the fourth month, physical and transvaginal ultrasound examination revealed a normal pelvis. Her pain became progressively worse, requiring oral analgesic almost daily. At the seventh month, ultrasound examination showed a hypoechogenic area inside the uterine cavity and bilateral tubular hypoechogenic cystic adnexal masses of 5 cm and 8 cm on the left and right sides, respectively, compatible with a hematometra with bilateral hematosalpinges. She was diagnosed to have postablation-tubal sterilization syndrome. The patient was advised to undergo either a laparoscopic assisted vaginal hysterectomy or laparoscopic bilateral sal-pingectomy together with hysteroscopic lysis of intrauterine adhesions. However, she declined further surgical treatment. Two months later, she had an episode of heavy menstrual flow and after that her lower abdominal pain was much improved. Subsequently, her menstrual flow became normal and the pain lessened. Ultrasound examination at the 16th month showed a reduction in the size of the hematosalpinges to 2 cm on the left side and 4 cm on the right side, but the hematometra persisted. Postablation-tubal sterilization syndrome was first described by Townsend et al. in 1993 (1). They reported the occurrence of lower abdominal pain and vaginal spotting in six women after roller-ball endometrial ablation. All of these women had had tubal ligation before. In five of the women the symptoms resolved after laparoscopic removal or cautery destruction of the affected fallopian tube, and the sixth woman required a hysterectomy because of recurrent symptoms on the opposite side. It was postulated that the symptoms occur because of the regeneration of the endometrium at the cornual region following an inadequate ablation. The outflow of subsequent cyclical menstruation was impeded by the scarring and adhesions in the lower part of the uterus, and was also blocked by the previous ligation. This is the first report of postablation-tubal sterilization syndrome after thermal balloon endometrial ablation. It has been suggested that to prevent the postablation-tubal sterilization syndrome, the cornual area should be adequately ablated (1). However, the balloon system was specifically designed to only partially enter the cornual areas to avoid potential thermal injury to the adjacent bowel. This sparing effect has been confirmed by Shah et al. in both ex vivo and in vivo models of thermal balloon endometrial ablation (2). In an observational study on the appearance of the endometrial cavity after thermal balloon ablation, we found that intrauterine adhesions occurred in 36.4% of cases (3). Therefore, in those patients who have had tubal ligation before, the retrograde menstruation from the cornual region may lead to the postablation-tubal sterilization syndrome. The management of all the previous cases was surgery. In our case, the improvement in her symptoms probably related to the partial spontaneous drainage of the hematosalpinges following the episode of heavy menstruation. This is supported by the shrinkage of the hematosalpinges as demonstrated on ultrasound examination. It would be interesting to follow-up this patient to see whether the pain recurs.