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Favorable pregnancy outcome in a woman with osseous metaplasia of the uterus
Abstract
We present an asymptomatic case of osseous metaplasia of the uterus, diagnosed 20 days after a spontaneous delivery, in a 25-year-old woman (para 1, gravida 2). Her first pregnancy ended in a mid trimester termination. The short interval between delivery and diagnosis, and the histological features of the lesion suggested that the intrauterine bone was already present before the second pregnancy was conceived.
... However, its frequency is thought to underestimate its actual incidence. This may be a result both of lack of adequate clinician experience and of the long asymptomatic phase of the pathology (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). In this case report, we review this rare disorder to reemphasize its diagnostic and therapeutic approaches. ...
... Endometrial ossification is a rare disorder. Although it first was reported more than a century ago, there still have been only a few cases reported up to date (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). It usually is seen in reproductive-age women. ...
... It usually is seen in reproductive-age women. Although pelvic pain, dysmenorrhea, abnormal bleeding, and the presence of bony particles in menstrual or vaginal discharge may also refer to it, secondary infertility is the most commonly cited symptom of these patients (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). ...
To present an endometrial osseous metaplasia case and reemphasize that the condition is a cause of secondary infertility.
Case report.
Department of Obstetrics and Gynecology in a university hospital in Turkey.
A 33-year-old multiparous woman was admitted to our institution with secondary infertility that had lasted for 2 years. She had experienced one first-trimester and one second-trimester abortion, 3 years and 2 years ago, respectively. On transvaginal sonography, a linear curvy echogenity was observed.
Hysteroscopic examination revealed multiple bony spicules, extending perpendicularly from the posterior uterine wall in to the uterine cavity and occupying almost two thirds of the cavity. Thereafter, a resectoscopic excision of the bony spicules was performed.
A normal endometrium and uterine cavity.
Two weeks after the operation, ultrasonographic evaluation was in the normal range, and the patient currently is trying to conceive spontaneously.
Although the role of office hysteroscopy in the evaluation of infertile couple is still under debate, clinicians should keep this rare disorder in mind, especially in patients with a history of late abortion, and should evaluate such cases by hysteroscopy when sonographic features are encountered.
... Pe achizițiile cu secvențe rapidă Spin-Echo (SE) -T1W și T2W se înregistrează ca și arii izo sau hipointense (39).Prognosticul reproductivEste esențială consilierea pacientelor privind prognosticul reproductiv după tratament, având în vedere că nu toate pacientele reușesc obținerea spontană a unei sarcini, există posibile consecințe obstetricale, iar unele paciente rămân simptomatice după evacuarea fragmentelor intrauterine (1,5).Lloyd et al. raportează în 2012 primul caz de placentă praevia cu aderență anormală (placenta accreta) la o pacientă cu istoric de metaplazie osoasă endometrială și infertilitate primară (40). Anterior, Basu et al. și Van den Bosch et al. raportauabsența unor consecințe negative asupra prognosticului obstetrical la pacientele cu antecedente de calcificări endometriale(41,42). ...
... Removal of bony fragments by hysteroscopy is associated with therapeutic success and correction of infertility, as reported in the literature. [4,[10][11][12][13][14][15][16][17][18] Khan et al. reported a spontaneous pregnancy rate of around 80% in one of the largest reviews on retained bones, [17] most of the pregnancies occurring 6 months after bone retrieval. ...
Background
Midtrimester surgical abortions often result in retained intrauterine fetal bones and consequent secondary infertility.
Aim
To study the incidence of women presenting with retained intrauterine bones as a cause of secondary infertility in a tertiary level Indian hospital and pregnancy rates following retrieval of these fragments.
Setting and Design
Retrospective data analysis in the infertility clinic of PGIMER (Post Graduate Institute of Medical Education and Research), a tertiary level hospital of Northern India.
Materials and Methods
Women diagnosed with retained intrauterine bony fragments were subjected to hysteroscopic removal of these fragments. Incidentally diagnosed retained bones on hysteroscopy were also removed. Such women were followed for spontaneous resumption of fertility or were subjected to ovulation induction, and pregnancy rates were noted.
Results
Retained fetal bones accounted for 0.28% of all women with infertility and 12% (22/144) of all the uterine causes of infertility requiring an operative hysteroscopic procedure for treatment. Only 5 (27.7%) of 18 women conceived after the hysteroscopic retrieval of bony fragments: three had full-term vaginal deliveries, one had a midtrimester abortion, and one woman is in her third trimester.
Conclusion
Despite surgical retrieval, fertility rates may be lower due to inflammatory damage to the endometrium.
... L'échographie montre typiquement une image hyperéchogène avec un cône d'ombre postérieur, des contours flous, souvent d'aspect linéaire, en situation intracavitaire [2][3][4][5][6][7][8], et persistante tout au long du cycle [1]. Cependant cette aspect peut prêter à confusion avec d'autres étiologies comme le polype endométrial calcifié -ce qui est le cas chez notre patiente-La tuberculose génitale, la métaplasie squameuse ou musculaire le fibrome calcifié, la calcification des artères du myomètre, la cicatrice stellaire post-césarienne ou postmyomectomie [9], les tumeurs malignes mullériennes, les tératomes ou enfin un corps étranger à type de DIU au cuivre [2]. ...
Corresponding author: Sofia Jayi, Service de Gynéco-Obstétrique 2, CHU Hassan II, 35, immeuble sebta, cité de police, avenue moulay youssef, BP 30 000, Fès, Maroc Abstract La métaplasie ostéoïde de l'endomètre (MOE) est une entité rare correspondant à la présence de tissu osseux dans l'endomètre, elle est le plus souvent diagnostiquée dans un contexte d'infertilité secondaire faisant suite à une grossesse interrompue. Même si plusieurs facteurs de risque sont répertoriés, sa physiopathologie reste mal connue et sa traduction clinique est très variable. Nous rapportons un cas de MOE apparu suite à un curetage pour rétention placentaire en post-partum. Le diagnostic a été suspecté par l'hystéroscopie et confirmé par l'étude anatomopathologique. A notre connaissance c'est le premier cas décrit suite à un accouchement à terme. A travers notre cas et à la lumière d'une revue de la littérature nous insistons sur les caractéristiques épidémiologiques, physiopathologiques, cliniques et para cliniques de cette entité rare, dont la connaissance est primordiale pour un diagnostic sûr et par conséquent un traitement adapté permettant souvent de récupérer la fertilité de la patiente.
... Van den Bosch et al. (9) noted an asymptomatic osseous metaplasia in the uterus 20 days after a spontaneous delivery. Because of the short time interval between delivery and diagnosis and the histologic characteristics of the lesion, they concluded that the osseous metaplasia originated from the first pregnancy that had been terminated during the middle trimester and was already present during the second pregnancy. ...
To report a case of osseous metaplasia of the cervix and endometrium as a cause of secondary infertility.
Case report.
Istanbul Bakirkoy Women and Children Teaching and Research Hospital.
A 31-year-old patient with secondary infertility owing to osseous metaplasia of the endometrium and cervix in whom uterine perforation occurred during the removal of bone fragments.
Diagnostic and operative hysteroscopy and laparotomy.
Visualization of the disappearance of the osseous metaplasia region with transvaginal ultrasound examination after the hysteroscopy intervention.
Osseous metaplasia lesions are removed by operative hysteroscopy. During this operation, laparotomy was done because of perforation of the uterine wall, and the perforated area was repaired. Two weeks after surgery, the patient underwent a transvaginal ultrasound examination, and the abnormal ultrasound appearance had resolved.
As a rare cause of infertility, osseous metaplasia can be seen in the cervix and the endometrium. If osseous metaplasia is deep enough during operative hysteroscopy, uterine perforation may occur. Clinicians must be careful for this reason, especially in cases of deep osseous metaplasia.
... of infertility. Hysteroscopic approach. Ginecol Obstet Mex 1999, 67:37-41. [21] Patient with infertility with hysteroscopic diagnosis of osseous metaplasia, which was resected surgically. 7 Van den Bosch T, Dubin M, Cornelis A: Favourable pregnancy outcome in a woman with osseous metaplasia of the uterus. Ultrasound Obstet Gynecol 2000, 15:445-447. [22] Patient with diagnosis of endometrial osseous metaplasia 20 days after a spontaneous delivery. The patient had had an abortion many years earlier. 8 Lainas T, Zorzovilis I, Petsas G, Alexopoulou E, Lainas G, Ioakimidis T: Osseous metaplasia: case report and review. Fertil Steril 2004, 82:1433-1435. [6] Case report of endometrial osseous ...
Endometrial ossification is an uncommon disease related to secondary infertility and its etiology and pathogenesis are controversial. More than 80% of reported cases occur after pregnancy.
A 33-year-old Caucasian woman was admitted with a history of secondary infertility and with a regular menstrual cycle. She reported a miscarriage at 12 weeks of gestation 7 years previously and subsequent dilatation and curettage in another medical facility. Vaginal ultrasound was performed and showed an intrauterine structure described as a hyperechogenic image suggesting calcification related to chronic endometritis. Office hysteroscopy revealed a wide endometrial cavity and proliferative endometrium, with a coral-like white plaque 1.5 cm in length on the right horn and posterior wall of the uterus. The lesion was treated by hysteroscopy without complications. Microscopic examination showed endometrial tissue with osseous metaplasia in the stroma. Nine months after the procedure, the patient became pregnant spontaneously.
In our patient, hysteroscopy was effective in the diagnosis and treatment of osseous metaplasia of the endometrium associated with infertility.
... Retrospective research revealed a case of favorable pregnancy outcome in a woman with osseous metaplasia of the uterus (9). In this case, the mass was embedded within the myometrium, with only a small spicule lying within the uterine cavity. ...
To discuss, through the experience of a case report and extensive literature review, the best practices for the diagnosis and treatment of osseous metaplasia, which is the cause of secondary infertility.
Case report.
In vitro fertilization unit in Athens.
A 40-year-old woman with a 10-year history of secondary infertility.
Hysteroscopic diagnosis and removal of the bony fragment.
Elimination of secondary infertility caused by osseous metaplasia.
After treatment, the woman underwent an IVF program and a healthy neonate was born with cesarean section.
Hysteroscopy remains the best practice for the diagnosis and removal of endometrial ossifications, causing secondary infertility.
La metaplasia ósea endometrial es una patología poco común que se asocia a infertilidad secundaria. La mayoría de casos se presenta en mujeres con antecedente de gestación no evolutiva. La sospecha se hace mediante el hallazgo de un endometrio hiperecogénico que se asemeja a la imagen de un dispositivo intrauterino. El gold standard para el diagnóstico y tratamiento es la histeroscopia con el estudio histopatológico del material obtenido en el precedimeinto. La importancia de su descripción es su presentación en una paciente nuligesta. Se describe el caso clínico y revisión de la literatura.
Introducrtion: Osseous metaplasia is a rare disorder (0.3/1000 women) of the endometrium that usually leads to secondary subfertility. Approximately 90% cases occur after previous late miscarriage or abortion. Exact aetiopathogenesis is unknown but there are numerous theories including endometrial stromal metaplasia, retention of bony particles from previous miscarriages etc. It is usually seen in reproductive-age women. Although pelvic pain, dysmenorrhea, abnormal vaginal bleeding can be present, secondary infertility is the most commonly cited symptom in these patients. Endometrial ossification may be encountered in cases with excessive consumption of calcium and/or vitamin D, metabolic disorders presenting with metastatic or heterotopic calcifications. The most common risk factor for this unique pathology is the presence of a previous midtrimester or late first-trimester abortion, both of which occur after the formation of fetal bones. Therefore, direct implantation of retained fetal parts is thought to be responsible for the presence of heterotopic uterine bone formation. However, there also are some rare case reports in the literature of nulliparous patients or of patients in whom abortion occurred in the very early gestational weeks, when no fetal bony tissue has been formed which can be explained by endometrial stromal metaplasia theory. Case report: We present a case of endometrial osseous metaplasia in a 26 year old woman with previous first trimester miscarriage which led to secondary subfertility. She was seen in Infertility clinic in Kingsmill Hospital. All her infertility work up was normal including hysterosalpingogram. Pelvic ultrasound showed echo-bright area in the cavity of the uterus. Therefore she had outpatient hysteroscopy which showed the presence of bone like structure in the endometrial cavity which was removed by Myosure XL morcellator. Following that she had normal uterine cavity. The histology confirmed bone formation in the endometrium. The patient conceived spontaneously within six weeks of bone removal and she is now nearly full term pregnant.
Three case-reports on endometrial ossification are described. This is a relatively rare condition, of which the etiology is not yet fully understood. Spontaneous or induced abortion or stillbirth are predisposing factors. Bone tissue in the uterine cavity may have a contraceptive function, comparable with an IUD. Removal of the bone tissue by hysteroscopy is the treatment of choice and may result in restored fertility.
Backgrounds:
What is not clear as yet is not only the etiology, but also the management of osseous metaplasia. We describe an infertile patient with osseous metaplasia and subsequent pregnancy after treatment and review the literature from infertility perspective.
Method:
We presented a 30-year-old woman with 8 years of secondary infertility who conceived spontaneously after removal of osseous tissue by operative hysteroscopy (HS) following one failed in vitro fertilization cycle. The current literature regarding the osseous metaplasia and fertility potential after removal of osseous tissue was also systematically reviewed in which 21 reports (n = 64 women) were eligible.
Results:
The available data suggest that restoration of endometrial cavity with HS or curettage provides a spontaneous pregnancy rate of 54.2% within 12 months.
Conclusion:
According to the available data, irrespective from the duration of subfertility, spontaneous pregnancy should be expected for at least 1 year following the 'complete' restoration of endometrial cavity. In that context, further infertility treatments such as assisted reproduction cycles should be postponed, unless there is another reason for infertility.
Calcification in the endometrial cavity is rarely encountered. Most cases presented with a secondary infertility. A possible explanation of infertility could be due to bone fragments acting as a foreign body initiating inflammatory process in the endometrium which makes it a hostile environment for the embryo to implant. We are reporting a case of secondary infertility with hysteroscopic findings of bony fragments in the endometrial cavity. Hysteroscopic removal of the fragments was followed by a normal pregnancy.
Two cases of endometrial osseous metaplasia of the endometrium in infertile patients with ressection of bony tissue by histeroscopy, followed by pregnancy
Objectives
The endometrial osseous metaplasia is a rare disease which is characterized by the presence of osseous tissue in endometrium. It is often diagnosed in women with secondary infertility. The main objective of this work is to evaluate fertility after elective resection of osteoid metaplasia endometrial lesions by operative hysteroscopy in infertile women.
Bony metaplasia of the endometrium. Report of two cases We report a 28-year-old female consulting for infertility and a 26-year-old woman consulting for severe dysmenorrhea. In both patients a osseous metaplasia of the endometrium was found. Both patients were subjected to a hysteroscopic resection of the osseous material and both achieved spontaneous pregnancies and term deliveries following the procedures. If the bony material is removed, normal pregnancies and deliveries are feasible afterwards, no matter how extensive is the the osseus metaplasia. (Rev Med Chile 2010; 138: 1004-1007). L a metaplasia ósea endometrial corresponde a la presencia de tejido óseo en el interior de la cavidad uterina. Es una patología de baja incidencia (0,3 x 1.000 mujeres) y en 80% de los casos existe el antecedente de abortos espontáneos o inducidos, generalmente de 12 semanas o más de gestación. No existe una teoría con respecto a su etiología, sin embargo, se han formulado múltiples hipótesis al respecto 1-29 . Clínicamente se presenta con metrorragia, dismenorrea, algia pélvica y flujo vaginal en oca-siones con restos óseos. También se ha asociado a infertilidad primaria y secundaria, especulándose que el tejido óseo podría ejercer una acción similar a un dispositivo intrauterino 4-10 . Comunicamos el caso de dos pacientes con diagnóstico de metaplasia ósea extensa endome-trial, dado el compromiso completo de la cavidad, que fueron sometidas a resectoscopía, logrando posteriormente un embarazo espontáneo.
We report a 28 year old female consulting for infertility and a 26-year-old woman consulting for severe dysmenorrhea. In both patients a osseous metaplasia of the endometrium was found. Both patients were subjected to a hysteroscopic resection of the osseous material and both achieved spontaneous pregnancies and term deliveries following the procedures. If the bony material is removed, normal pregnancies and deliveries are feasible afterwards, no matter how extensive is the the osseus metaplasia.
We present a case of a 27-year-old asymptomatic woman, gravida 2 para 0 abortus 2, diagnosed with uterine intramural fetal bone 30 days after a mid-trimester termination of pregnancy (TOP) by dilatation and evacuation (D&E). On ultrasound part of a fetal spine was seen within the right lateral isthmocervical area, adjacent to the descending branch of the uterine artery. Within 4 months after TOP the patient conceived again. This case illustrates the risk of myometrial penetration during mid-trimester TOP by D&E. Removal of intramural bony fragments may not be needed in an asymptomatic patient, as their presence does not seem to compromise fertility.
Hysteroscopic examination in a woman with secondary infertility revealed calcified tissue in the uterine cavity. Histopathological examination demonstrated mature bone. Genetic analysis supports its fetal origin.
The frequent presence of small echogenic foci within the inner myometrium in women who have had prior uterine instrumentation is reported. Bright foci were observed in 35 of 80 patients who had had prior dilatation and curettage or endocervical biopsy and in only 2 of 174 patients who gave no history of either procedure (P less than 0.005). These foci tend to be small (3 to 6 mm), linear, usually nonshadowing, single or multiple, and located immediately adjacent to the endometrium anywhere along the length of the endometrial cavity; they can be seen many years after the procedure was performed. The histopathologic features of these foci are unconfirmed, but we suspect they represent calcification or fibrosis at sites of mechanical injury to myometrium. The presence of these foci serves as a marker of prior instrumentation and probably has no clinical significance. However, sonographers who are aware of their possible occurrence, can avoid mistaking them for leiomyoma calcifications or for air in the endometrium or myometrium in patients with suspected endometritis.
There are only about 90 cases described in the literature of the presence of an intra-uterine osseous structure--so the condition is not a common one. Often the aetiology is unknown. The purpose of this work is to describe the clinical picture and the anatomo-pathological characteristics on one form which leaves practically no doubt as to how the presence of bony structures in the uterus arise. We call this residual endometrial-ossification (O.R.E.) and note osteogenic or osseous metaplasia. We define O.R.E. as the presence of an osseous structure inside the uterus which does not arise from metaplasia of the cells of the endometrium.
Four patients with symptomatic intrauterine retention of fetal bones are discussed. Presenting complaints included infertility, irregular vaginal bleeding, vaginitis, and spontaneous passage of fetal bones. Two patients had uterine anomalies, 1 patient had a retained twin pregnancy. Pelvic ultrasound and x-ray films of the pelvic cavity are helpful in making a diagnosis. Hysteroscopy is invaluable both in confirming the diagnosis and in achieving successful removal of fetal bone. © 1982 The American College of Obstetricians and Gynecologists.
Hysteroscopic removal of ectopic bone in the uterus, using laparoscopic control and ultrasonographic confirmation, was used to treat a patient who presented with a diagnosis of osseous metaplasia of the uterus. Pathologic analysis revealed benign bony tissue consistent with a diagnosis of osseous metaplasia. Laparoscopy and hysteroscopy confirmed the presence of bone in the form of spicules perpendicular to the uterine endometrium. Most of the bone was present in the posterior portion of the fundus. Initial removal was performed with biopsy forceps followed by gentle curettage. The resectoscope was then introduced to visualize any remaining spicules and remove them by mechanical means with minimal use of electrosurgery. Transvaginal ultrasound assisted in identifying bone and confirming its removal during and after surgery. The hysteroscopic procedure was viewed laparoscopically to reduce the risk of uterine perforation. Dense right adnexal adhesions were also lysed. The patient received conjugated equine estrogens for five weeks post-operatively. Ultrasound showed an intrauterine pregnancy of 5 to 6 weeks plus two small calcifications approximately 1 mm each. The patient delivered a healthy infant and has had no recurrent problems. This case report demonstrates the successful use of multiple diagnostic and treatment modalities in the treatment of ectopic intrauterine bone.
In the past, most cases of osseous metaplasia of the endometrium were diagnosed following removal of bone from the endometrium by dilatation and curettage and frequently subsequently treated by hysterectomy. Nowadays, management involves a suggested diagnosis by transvaginal ultrasound examination, confirmation by hysteroscopy and hysteroscopic removal of ectopic intrauterine bone. This is usually carried out under laparoscopic guidance. However, the degree of visual control provided by combined transabdominal and transrectal ultrasonography may prove sufficiently accurate for hysteroscopic guidance. In this report we describe a case of endometrial osseous metaplasia successfully managed by ultrasound-guided hysteroscopy. The advantages of our approach include reduced invasiveness, reduced costs and simultaneous visualization of the abdominal and intrauterine cavities. One limitation, however, is represented by the greater operator dependence of ultrasound guidance as compared to laparoscopy, the former requiring extensive training and state-of-the-art equipment.
We suggest that ultrasound guidance for hysteroscopic removal of extensive osseous metaplasia may represent a potentially safer and more effective alternative to laparoscopy and would therefore encourage further clinical evaluation of this technique. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology
A "strongly attached white rough incrustation" was found on intrauterine devices (IUDs) (especially the Szontagh Copper T 200 and Lippes Loop) removed after several years and associated with abdominal symptoms. A weak correlation (r = 0.42) was found between the proportion of incrustation and the time of use. The primary component of the incrustation was calcium carbonate. Incrustations irritate the endometrium and can lead to infection. The symptoms include lower abdominal pain an elevated sedimentation rate an increased white blood cell count and a raised body temperature. High-resolution ultrasonography was used to compare newly inserted IUDs with IUDs worn for a long period of time or associated with symptoms. The long shanks of the Copper T 200 produced a typical continuous echo of thick parallel lines; when incrusted their surfaces were hyperreflective. Small amounts of incrustation are difficult to demonstrate with a copper IUD because of the hyperreflectivity of the metal. A control device produced a thin parallel linear echo. The linear echos of an incrusted Szontagh IUD appeared uneven with circumscribed areas of hyperreflectivity; the unincrusted device presented only thin linear echoes.