1. Endometrial ablation Endometrial ablation broadly describes a group of hysteroscopic procedures destroys or resects the endometrial lining of the uterus to sufficient depth prevents regeneration of the endometrium and lead to eumenorrhea. For many women, ablation serves as a minimum invasive and effective treatment of abnormal uterine bleeding.

2. Indications: Endometrial ablation is used to treat many cases of heavy uterine bleeding which cannot be controlled with medication. Who should not have endometrial ablation? Prior to ablation, complete evaluation of abnormal uterine bleeding should be completed. Accordingly, it is not recommended for women with certain medical conditions, including the following :

3. Genital tract malignancy. Woman wishing to preserve fertility. Pregnancy. Expectation of amenorrhea. acute pelvic infection. Prior uterine surgery e.g. classical C/S and transmural myomectomy. Uterine size >12 weeks.

4. Techniques used for endometrial ablation : These are first or second generation depending on their temporal introduction into use and the need for hysteroscopic skill. First generation tools require advanced hysteroscopic skills and longer operating times and can be associated with distension medium complications, these tools include:

5. A-Neodymium : yttrium-aluminum – gamet (Nd-YAG)Laser. It was the first ablative tool, introduced in the 1980 s. Under direct hysteroscopic observation and uterine distention with saline,a Nd-YAG laser fiber touches the endometrium and is dragged across the endometrial surface. This creates furrows of photocoagulated tissue that are 5 to 6 mm deep.

6. B- Transcervical Resection of the endometrium (TCRE). In attempt to lower cost from expensive laser equipment, TCRE was developed. In addition to less expensive, because of larger loop diameter, TCRE can be completed more quickly than laser fiber ablation & can thereby reduce the risk of excess media absorption due to long procedure duration. In cases with concurrent intrauterine pathology such as endometrial polyps or submucous leiomyoma, TCRE, can excise these lesions in addition to the endometrium.

7. However, TCRE has been associated with higher rate of perforation, especially at the cornual areas, where endometrium is thinner. For this reason, many used a roller ball electrosurgical electrode in combination with TCRE, with roller ball used in the cornua

8. C-Roller ball. A 2-4 mm ball-shaped or barrel shaped electrosurgical electrode can be rolled across the endometrium as an effective means of vaporizing the endometrium. Advantages of roller ball ablation compared with TCRE include: shorter operative time, less fluid absorption and lower rate of perforation. Unfortunately, it is not effective in the treatment on intracavitary lesions, and pathology specimens are not obtained.

9. To reduce risks and the specialized training required for use of these early ablative tools, second – generation nonresectoscopic methods have been introduced during the past 10 years. These tools use various modalities to ablate the endometrium but do not require hysteroscopic guidance. Modalities include :

10. 1-Thermal balloon ablation The first thermal balloon ablation system was initially used in the early 1990s. Several thermal balloon ablation systems are currently used worldwide. Only the ThermaChoice III Uterine Balloon Therapy System is approved for use in the United State. After cervical dilation to 5.5 mm, the ThermaChoice device is inserted into the cavity, a 5% dextrose and water solution is instilled into a disposable, clear silicone balloon at the tip and heated to coagulate the endometrium.

11. During the treatment, the fluid within the balloon is circulated to maintain a temperature of 87°c (186° F) for 8 minutes. The balloon can be introduced without hysteroscopic assistance into the uterine cavity and when inflated, conforms to the cavity contour. All hot-liquid balloon devices require no advance hysteroscopic skills, and complication rate are low. Disadvantages include the requirement of an anatomically normal uterine cavity and of pharmacologic thinning prior to thermal ablation. Alternatively, mechanical thinning can be accomplished with dilatation and curettage prior to ablation.

12. 2- Cryoablation Endometrial ablation can be achieved with extreme cold. This system was approved for use in the United State in 2001. Similar to the physics of cervical cryotherapy, gases compressed under pressure with this unit can generate temperatures of -100° to -120° C at the cyroprobe tip to produce an ice ball. As an ice ball grows, its leading edge advances through tissue, and cryonecrosis develops in those tissues reaching temperature less than -20°C. After cervical dilatation, the cyroprobe s 1.4 inch cryotip is placed against one side of the endometrial cavity and advanced to one uterine cornua.

13. Concurrent transabdominal sonography is required to ensure accurate cryotip placement and surveillance of the increasing ice ball diameter, which is seen as an Enlarging hypoechoic area. The first freeze is terminated after 4 minutes or sooner, if the advancing iceball reaches to within 5 mm of the uterine serosa. The cryotip is allowed to warm, is removed from the cornua, and is redirected into the contralateral cornua.

15. 3-Microwave Ablation The microwave endometrial ablation (MEA) technique uses microwave energy to destroy the endometrium. During the procedure, a microwave probe is inserted until the tip reaches the uterine fundus. Once inserted, the probe tip is maintained at 75°c to 80°c and moved slowly from side to side. Microwave energy is spread with a minimum penetration of 6mm over the entire surface of the uterine cavity. Speed is an advantage, with the entire treatment completed in 2 to 3 minutes. Due to complications of bowel burns in patients without evidence of uterine perforation, to obtain FDA approval, the manufacturers of the MEA system recommend preoperative assessment of myometrium thickness at least a 10 mm thickness throughout the uterus.

16. 4- Impedance-controlled Electocoagulation The NovaSure endometrial ablation was approved for marketing in the United State in 2001. The system consist of high-frequency (radiofrequency) bipolar electrosurgical generator and a single-use, metal, fan-shaped device constructed of fabric –like mesh. The mesh fan is designed to contour to the shape of the endometrial cavity. The treatment time of 2 minutes results in desiccation of endometrium. An advantage of this system is that it does not require preoperative endometrial preparation and it has been used successfully in patients with small submucosal lieomyomas and poylyps.

18. 5-hysteroscopic thermal ablation The Hydro ThermAblator (HTA) system allows treatment of the endometrium concurrent with submucous lieomyomas, polyps, or abnormal uterine anatomy. Another advantage is that it is performed under direct hysteroscopic visualization, allowing the surgeon to observe the endometrium being destroyed.

19. This tool is designed to ablate the endometrial lining of the uterus by heating an uncontained saline solution to a temperature of 90°C and circulating it through the uterus for 10 minutes. Spill through the fallopian tubes is avoided because hydrostatic pressure during the procedure remains below 55mm Hg, which is well below pressures needed to open the fallopian tubes to peritoneal cavity. Similarly, the water seal created between the hysteroscope and internal cervical os prevents leakage of fluid into the vagina. For this reason, care should be taken nor to dilate the cervix to a diameter more than 8mm.

21. Can I get pregnant after having endometrial ablation? Pregnancy is not likely after ablation, but it can happen. If it dose, the risk of miscarriage prematurity, abnormal placentation & perinatal morbidity are increase. If a woman still wants to become pregnant, she should not have this procedure. Some women choose a sterilization procedure at the time of endometrial ablation to prevent pregnancy.

22. What should I expect after the procedure? After endometrial ablation, you may experience: Cramps. You may have menstrual- like cramps for a few days. Over the counter medications such as ibuprofen or acetaminophen can help relieve cramping after the procedure. Vaginal discharge. A watery discharge, mixed with blood, may occur for a few weeks. The discharge is typically heaviest for the first few days after the procedure. Frequent urination. You may need to pass urine more often during the first 24 hours after endometrial ablation. You may need to avoid intercourse and tampon use for a period of time after the procedure. It may take a few months to see the results, but endometrial ablation usually succeeds in reducing the amount of blood lost during menstruation.

23. The success rates As a general role, of all women undergoning endometrial ablation with second generation technique 40% will become amenorrhoeic 40% will have markedly reduced menstrual loss 20% will have no difference in their bleeding.

24. The risks associated with endometrial ablation :  A puncture injury (perforation) of the uterine wall from surgical instruments.  Heat or cold damage to nearby organs.  Pain, bleeding or infection.  Fluid over load due to absorption of distension medium (resection only).

25. Postoperative  Advantage to endometrial ablation include rapid patient recovery and low incidence of complications. Patients may resume normal diet and activities as tolerated.  Patients may expect light bleeding or spotting during the first postoperative days as necrotic endometrial tissue is shed. A serosanguinous discharge follows for 1 week and is replaced by a profuse and watery discharge for another 1 to 2 weeks.

26. Thank you