Hysteroscopic surgery which can observe and remove the intrauterine lesions is a minimally invasive and essential procedures in recent gynecology. At present, the continuous flow monopolar or bipolar resectoscope is still considered the first-choice instrument to perform major operative hysteroscopical and urological procedures. However, whereas these instruments are excellent as far as excisions and hemostasis are concerned, thermal damage of the healthy endometrium is unavoidable.

The intrauterine Bigatti shaver (IBS®) is a relatively new method for removing endometrial masses such as polyps and fibroids [1]. The rigid shaving system consists of two hollow reusable metal tubes fitting to each other. The inner tube rotates within the outer tube. The rotating and oscillating movement of the inner blade of the shaving system cuts the tissue and allows aspiration of specimens for histology. A correct fluid balance is calculated to maintain optimal distension and visualization inside the uterine cavity. Normal saline solution used for irrigation is inexpensive and economical [2-4].

From March 2020, we have performed hysteroscopy with the IBS®.  We present the three surgical cases successfully treated with IBS. Informed consents were obtained from all the patients.

The endmetorial polyp, Asherman's syndrome 

42 years old nulliparous woman visited our hospital suffering from irregular genital bleeding and infertility. Hysteroscopy revealed the polyp and the extensive intrauterine adhesion. Resectoscopy by using IBS was performed.

https://vimeo.com/manage/videos/914690592

Narration on The Video 1

A polyp lesion at the top and an intrauterine adhesion the shape of a crescent at the bottom can be seen in this image. Firstly, the polyp is being surgically removed with IBS. Secondly, the adhesion is being shaved. The uterine ostium of fallopian tube is visible on the right.

Postoperatively, irregular bleeding has stopped, and the patient's progress is presently monitored with outpatient visits.

Intrauterine foreign body

72 years old 2 Gravidity 2 Parity woman visited our hospital suffering from a green discharge. A contraceptive ring was left in the womb some 30 years ago after its insertion.

The cytology of the cervix and endometrium were normal. Resectoscopy using IBS was performed in order to remove the IUD.

https://vimeo.com/manage/videos/914691684

Narration on the video 2

The thread of IUD can be seen.

Shaving begins as the thread is being traced.

A part of the IUD is exposed.

Most of the IUD is exposed.

Gripping forceps was inserted through the IBS channel and the IUD was removed from the uterine cavity.

Postoperatively, the green-colored discharge has stopped, and the patient's progress is presently monitored with outpatient visits.

Stenosis of the uterine cervix

42 years old nulliparous woman visited our hospital for infertility treatment. Because the transcervical embryo transfer was impossible due to the stenosis of the uterine cervix, transmyometrial embryo transfer [5,6] was performed, but embryo implantation failed.   

Resectoscopy using IBS was performed in order to repair the stenosis.

https://vimeo.com/manage/videos/914692430

Narration on The Video 3

A step is being visible here intra uterine cervix.

Here, the step is being shaved.

After its removal, the uterine cervix becomes flat.

Smooth insertion of a catheter was possible after the surgery, so it became possible for the patient to get pregnant and have a normal vaginal delivery after the first embryo transfer was successful.

Unlike the conventional resectoscopy, the main advantage of the IBS® is that the tissue chips or adhesions were removed without any thermal damage occurring on the endometrium. Bipolare or Monopolar device could lead to the thermal damage of the surrounding healthy endometrium. IBS is able to remove the lesion in the narrow space around the uterine ostium without the thermal damage of the endometrium.

https://vimeo.com/manage/videos/914693353

The thermal damage of healthy endometrium should be avoided in view of reproduction. The IBS® should be proactively used in younger women in their reproductive age.

Further investigations are needed to determine its utility for patients whose fertility preservation is requested.

It is reported that the IBS is a much faster learning curve [7]. There was a statistically significant difference in the operating times of patients operated with conventional bipolar resectoscope, but not in the case of patients operated with the IBS® between the expert surgeon and the resident. It suggests that the IBS® technique is much easier to use and the experience of the surgeon was not the most important [7].

Case 3 showed a difficult passage of the catheter due to Cervical stenosis. In a situation like this, grasping of the cervix with a tenaculum usually makes the passage possible, otherwise, a transmyometrial embryo transfer is performed.

However, these procedures cause a significant increase in junctional zone contractions associated with a negative outcome [8-10] and should be avoided as much as possible.

There is some evidence in the published literature that opening the cervix was clearly related to smooth passage of the catheter and contribute to improving treatment results [11-14]. Therefore, sharpening stenosis portion of the cervix for the smooth passage of the catheter by using devices such as the IBS® might have a certain effect for a positive outcome.

Further prospective studies are needed to investigate the most effective method of embryo transfer in cases where a difficult transcervical embryo transfer is expected due to cervical factors.

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12. Yanushpolsky EH, Ginsburg ES, Fox JH, Stewart EA. Transcervical placement of a malecot catheter after hysteroscopic evaluation provides for easier entry into the endometrial cavity for women with histories of difficult intrauterine inseminations and/or embryo transfers: A prospective case series. Fertil Steril. 2000; 73: 402-405.
13. Serhal P, Ranieri DM, Khadum I, Wakim RA. Cervical dilatation with hygroscopic rods prior to ovarian stimulation facilitates embryo transfer. Hum Reprod. 2003; 18: 2618-2620.
14. Yang L, Rajesh H, Yu S. The Intrauterine Bigatti Shaver for Endometrial Lesions: Our Experience and Modifications. Open J Obstet Gynecol. 2017; 7: 1-6.