|
 |
| ORIGINAL ARTICLE |
|
| Year : 2020 | Volume
: 18
| Issue : 2 | Page : 53-58 |
|
Hysterolaparoscopy (pan-endoscopy) in the management of female infertility in Nigeria: A report of 230 cases
Joseph Odirichukwu Ugboaja1, Charlotte Blanche Oguejiofor1, Onyecherelam Monday Ogelle2
1 Department of Obstetrics & Gynaecology, Nnamdi Azikiwe University, Teaching Hospital, Nnewi, Nigeria
2 Blessed specialist Hospital & Maternity, Onitsha, Nigeria
| Date of Submission | 20-Jun-2020 |
| Date of Decision | 07-Jul-2020 |
| Date of Acceptance | 08-Jul-2020 |
| Date of Web Publication | 07-Aug-2020 |
Correspondence Address:
Dr. Joseph Odirichukwu Ugboaja
Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/NJGP.NJGP_9_20
Background: Hysterolaparoscopy has emerged as a better evaluation tool than laparoscopy and dye test in cases of infertility because of the ability to evaluate intra uterine lesions. Objective: To examine the role of Hysterolaparoscopy in the management of infertile women who were seen in 2 Fertility/ Gynaecological Endoscopy units in Nigeria. Methods: A cross sectional descriptive survey of the first 230 infertile women who were managed in the fertility and Gynaecological endoscopy units of Nnamdi Azikiwe University Teaching Hospital Nnewi Anambra State, Nigeria and Holy Rosary Specialist Hospital & Maternity, Onitsha, Nigeria. Data were analyzed with STATA software, version 12.0 SE (Stata Corporation, TX, USA). Result: The mean age of the women was 35.6+/- 5.9 years and the mean duration of infertility was 4.6+/- 2.7 years. More than half (53.9%. n=43) of the women had secondary infertility. Ninety -eight (42.61%) of the women had done a pelvic surgery in the past and pelvic ultrasound study was abnormal in 95(41.3%) of them. Abnormal hysteroscopy was found in 152 (66.1%) of the women and comprised mainly of intrauterine adhesions (41.%; n=95), endometrial polyps (20.%; n= 46), submucous fibroids (16.1%; n=37) and mullerian duct abnormalities (14.8%; n=34). Other findings were lost IUCD (6.1%'n=14), retained fetal bone (2.6%; n=6) and incarcerated omentum (2.2%; n=5). Abnormal laparoscopy findings were seen in 171 (74.4%) of the women. The main abnormal laparoscopy findings were tubal pathologies (161, n=70.0%), pelvic adhesions (39.6%, n=91), polycystic ovaries (33.0%; n=76), and endometriosis (8.8%, n=19). Tubal pathologies comprised mainly tubal occlusions (56.5%, n=130), hydrosalpinx (41.7%, n= 96) and plastered tubes (25.7%, n=59). Bilateral tubal occlusion was seen in 46 (20.0%). Conclusion: Hysterolaparoscopy is an effective tool for evaluating tuboperitoneal and intrauterine lesions among infertile women. There is a need to develop the capacity for this investigative modality.
Keywords: Dye test, hysterolaparscopy, intrauterine lesions
How to cite this article:
Ugboaja JO, Oguejiofor CB, Ogelle OM. Hysterolaparoscopy (pan-endoscopy) in the management of female infertility in Nigeria: A report of 230 cases. Niger J Gen Pract 2020;18:53-8 |
How to cite this URL:
Ugboaja JO, Oguejiofor CB, Ogelle OM. Hysterolaparoscopy (pan-endoscopy) in the management of female infertility in Nigeria: A report of 230 cases. Niger J Gen Pract [serial online] 2020 [cited 2023 May 29];18:53-8. Available from: https://www.njgp.org/text.asp?2020/18/2/53/291607 |
| Introduction | |  |
Infertility is the most common indication for seeking gynecological consultation in Nigeria [1],[2],[3] and is usually associated with immense psychosocial challenges because of the high premium placed on childbirth. The cause of infertility may be male factor abnormalities, female factor abnormalities, or both.
Female factors could be tuboperitoneal pathology, ovulatory dysfunction, endometrial lesions, or occasionally cervical factor. The common investigative modalities for the assessment of tubal pathology include hysterosalpingography (HSG), laparoscopy and dye test, and sometimes sonohysterosalpingogram or hysterocontrast sonogram.
HSG has been the traditional method of tubal evaluation before the advent of laparoscopy and it's still used widely especially among the developing countries.[4],[5],[6],[7] It has the advantage of being less invasive, requires less skill and facility, and has the additional advantage of being able to assess the uterine cavity for lesions that may be impairing fertility. As a result, HSG has remained the most widely used modality for the evaluation of female infertility within the resource-poor regions of the world including Nigeria.
Laparoscopy and dye test, though more invasive than HSG, is the gold standard for the evaluation of the tuboperitoneal factors in infertility. Its disadvantages, however, include the requirement for skill and equipment, the invasive nature, and the inability to assess the uterine cavity. There is the limited use of laparoscopy and dye test in the evaluation of infertility in Nigeria.[8],[9],[10]
To accommodate and take care of the inability of laparoscopy and dye test to evaluate the uterine cavity, hysteroscopy done at the time of laparoscopy and dye test has been introduced in a procedure termed hysterolaparoscopy or panendoscopy. This approach has been shown to be very useful and superior to either laparoscopy and dye test alone or HSG in the evaluation and management of infertility.[11],[12],[13],[14],[15]
Hysterolaparoscopy is done as in the usual laparoscopy and dye test but preceded by diagnostic hysteroscopy. The procedure is normally done in the immediate postmenstrual phase under general anesthesia.
During hysteroscopy, the cervical canal, uterine cavity, and tubal ostia are systematically examined for contour and lesions, while in the accompanying laparoscopy, the pelvic cavity, the tubes, ovaries, adnexa, and Pouch of Douglas are also examined for lesions which are noted and recorded, if present. This is followed by the injection of methylene blue solution into the uterus through the Spackman's cannula or dye injector and then observation for tubal spillage through the laparoscope.
In Nigeria so far, there are no reports on the use of hysterolaparoscopy in the management of infertility. The few available reports are on the use of HSG or laparoscopy and dye test as stand-alone procedures.
This study, therefore, aims to present our experience with the use of hysterolaparoscopy in the management of infertility in two fertility units in Nigeria.
Main objective
The main objective of this study is to examine the contribution of hysterolaparoscopy to the management of infertile women attending two fertility clinics in Nigeria.
Minor objectives
- To study the sociodemographic and clinical characteristics of the women
- To study the abnormal findings at hysteroscopy
- To study the abnormal findings at laparoscopy
- To make recommendations for the use of hysterolaparoscopy in Nigeria.
Study setting
The fertility and gynecological endoscopy units of Nnamdi Azikiwe University Teaching Hospital Nnewi Anambra State, Nigeria, and Holy Rosary Specialist Hospital and Maternity, Onitsha.
Study design
A cross-sectional descriptive survey of the first 230 infertile women who were managed in the units.
Study population
The consecutive women who gave consent for the study were recruited. Those who withheld consent were excluded from the study.
| Methods | | |
At presentation, a pro forma was used to collect the data on the biosocial, reproductive, and disease characteristics of the women. The information obtained specifically included the biosocial data, the presenting complaint, menstrual pattern, reproductive performance, and the type and duration of infertility.
The women were then worked up and booked for hysterolaparoscopy done under general anesthesia in the immediate postmenstrual phase for the women who menstruate but at any convenient time for the amenorrheic women. The procedure was done with the Carl Storz (Germany) laparoscopy equipment and hand instruments while the hysteroscopes used were techno (Germany).
The procedure was usually started with diagnostic hysteroscopy procedure and then followed by laparoscopy and dye test. If lesions were seen during hysteroscopy, they are removed using either the operative hysteroscope with scissor and graspers or the resectoscope with monopolar current using glycine as the distending media. Similarly, lesions seen during diagnostic laparoscopy or already diagnosed in the clinic with transvaginal ultrasound scan were also treated.
At the end of the procedure, the attached pro forma was then completed with the findings and surgical interventions carried out during the procedure. The patients were discharged the same day on oral antibiotics and analgesics and given a 1 week appointment at the clinic.
At the follow-up clinic, the findings from the procedure and any intervention done during the procedure, with subsequent management plan were discussed with the couple including the management plan. They were given the reports including the video of the procedure and then followed up. When they become pregnant, an early ultrasound was done to confirm, locate, and date the pregnancy and they are moved over to the antenatal clinic.
Data analysis
Data were analyzed with STATA software, version 12.0 SE (Stata Corporation, TX, USA). Simple descriptive statistics were carried out to determine the frequencies of the variables.
Ethical clearance
Ethical clearance was gotten from the Nnamdi Azikiwe University Teaching Hospital Ethics review board and the ethical principles of nonmaleficence, beneficence, confidentiality, and respect of persons were applied throughout the duration of the study. The patients were well counseled on the purpose of the study and they all gave consent. Those who withheld consent were excluded from the study.
| Results | | |
Sociodemographic characteristics of the women
As shown in [Table 1], the age of the women ranged from was 21 to 46 years, with a mean of 35.6 ± 5.9. The modal parity group was 0–1 (87.8%). Primary infertility accounted for 106 (46.1%) of cases. Majority (42.2%) of the women were public servants and had acquired tertiary education (76.1%). | Table 1: Distribution by the Sociodemographic characteristics of the women
Click here to view |
Clinical characteristics of the women
The clinical characteristics of the women are shown in [Table 2]. Secondary infertility accounted for (53.9%) of the cases and the mean duration of infertility was 4.6 ± 2.7 years. Secondary dysmenorrhea, deep dyspareunia, and chronic pelvic pain were seen in 59 (25.7%), 62 (27.0%), and 48 (20.9%) of the women, respectively. Ninety-eight (42.61%) of the women had done a pelvic surgery in the past and pelvic ultrasound study was abnormal in 95 (41.3%) of the women.
Abnormal findings at hysteroscopy among the women
As shown in [Table 3], 152 (66.1%) of the women had abnormal findings at hysteroscopy. The lesions detected were intrauterine adhesions (IUAs) (41.3%; n = 95), endometrial polyps (20.0%; n = 46), submucous fibroids (16.1%; n = 37), and Mullerian duct abnormalities (14.8%; n = 34). Other findings were lost intrauterine contraceptive device (IUCD) (6.1%'n = 14), retained fetal bone (RFB) (2.6%; n = 6), and incarcerated omentum (2.2%; n = 5). IUAs were mainly moderate (38.9%; n = 37) in severity while the submucous fibroids were mostly of type 0 (56.8%; n = 21). The most common Mullerian abnormality seen was arcuate uterus (41.2%; n = 14). | Table 3: Distribution by tuboperitoneal pathologies found among the women
Click here to view |
Abnormal laparoscopy findings among the women
Abnormal laparoscopy findings were seen in 171 (74.4%) of the women while tubal pathologies were seen in 161 (70.0%) of the women and comprised mainly of tubal occlusion (56.5%, n = 130), hydrosalpinx (41.7%, n = 96), and plastered tubes (25.7%, n = 59). Bilateral tubal occlusion was seen in 46 (20.0%) and unilateral tubal occlusionn in 84 (36.5%) of cases. Proximal tubal occlusion accounted for 73 (56.2%) of all cases of tubal occlusion. Pelvic adhesions and endometriosis were found in 91 (39.6%) and 19 (8.8%) of the women, respectively [Table 4].
| Discussion | | |
Tuboperitoneal and intrauterine pathologies contribute significantly to the burden of infertility in Nigeria and hysterolaparoscopy have been found very useful in the evaluation and management of cases.[11],[12],[13],[14],[15] We found a prevalence rate of 74.4% of tuboperitoneal abnormalities which comprised mainly tubal occlusions, pelvic adhesions, polycystic ovaries, and endometriosis.
This rate of tuboperitoneal disorders was high and similar to 72.1% earlier reported by Bukar et al.[6] in their review of 272 women investigated for infertility in the northeastern Nigeria and 70.0% found by Mbaye et al.[16] among 128 women being evaluated for tubal factor infertility in Dakar, Senegal in 2012. They also found pelvic infection in 39.8% of the women.
The main tuboperitoneal disorder found in our work was tubal occlusion which was seen in 130 (56.5%) of the women and consisted of bilateral tubal occlusion in 20.0% and unilateral tubal occlusion in 36.5% of cases. This rate is high and similar to a prevalence rate of 56.8% reported by Akinola et al. in Lagos, Nigeria [17] and 54.6% reported in Abakiliki, Southeastern Nigeria.[7] It is, however, higher than 44.9% and 43.5% reported in Nigeria by Otolorin et al.[10] and Okafor et al.,[4] respectively, but lower than 67.2% and 60.4% previously reported by Adesiyun et al.[18] and Ikechebelu and Mbamara [9] in Nigeria.
The prevalence rate of 38.6% of pelvic adhesions found among our women was high and could account for a significant number of tubal occlusions. This was reflected in the significant history of deep dyspareunia, secondary dysmenorrhea, and chronic pelvic pain, symptoms that are known markers of pelvic adhesive disease. Our finding is, however, <55.1% reported by Otolorin et al.[10] and 42.7% reported by Ikechebelu and Mbamara.[9] Efforts to reduce the burden of infertility in Nigeria and other African countries should also focus on reducing postoperative adhesions following pelvic surgeries notably myomectomy and cesarean section.
We found endometriosis in 19 (8.8%) of the women. This is higher than 4.4% reported by Ikechebelu and Mbamara [9] and 1.4% reported by Otolorin et al.[10] among infertile women undergoing laparoscopic evaluation of tubal factor in infertility. However, it was much lower than 29.6% reported by Zhang et al. in China infertile women.[12]
Although the relationship between mild endometriosis and infertility is not clearly understood, severe endometriosis cause infertility by tubal occlusion and also distortion of the tubo-ovarian relationship necessary for ovum pick up by the fimbriae end of the tube. Endometriosis also gives rise to extensive adhesions that can also occlude the tubes. In addition, the associated deep dyspareunia and chronic pelvic pain cause sexual dysfunction with reduced sexual intercourse which further reduces the chances at conception.
Endometrial pathologies contribute significantly to infertility in Nigeria and abnormal hysteroscopies are found in as many as 77.4% of infertile women. Our study found a prevalence rate of 66.1% of endometrial pathologies among the studied women. This rate is high but lower than 77.0% and 76.0% reported by Okohue et al.[19] in Port Harcout, Nigeria and Ajayi et al.[20] in Asaba, South-south Nigeria.
The most common intrauterine lesion detected in our study was IUAs. This is similar to previous reports in Nigeria.[19],[20] and elsewhere.[15] These IUAs are caused by posttraumatic or postinfectious trauma to the basal layer of the endometrium, resulting in scarring of the endometrium leading to the obliteration of the cavity. The common precipitating events include dilatation and curettage for pregnancy-related events, myomectomy, cesarean section as well as hysteroscopic surgeries.
The second most common pathology detected by our study was endometrial polyps. This is also similar to the previous reports in the country.[19],[20] Endometrial polyps are localized overgrowth of the endometrium, which may be single or multiple. The true incidence of endometrial polyps in the general population is unknown because many of them are asymptomatic and discovered during the routine evaluation of infertile women. The mechanism through which polyps cause infertility is still unknown, but improved reproductive outcomes have been noted in patients following polypectomy. Specifically, hysteroscopic removal of endometrial polyps before intrauterine insemination (IUI) has being shown to improve clinical pregnancy rates and reduce early pregnancy failures.[21]
It has also been reported that polypectomy increases implantation and clinical pregnancy rates in women with recurrent implantation failure following in vitro fertilization.[22] Even among patients being worked up for IUI, 65% were noted to achieve spontaneous pregnancies following polypectomy.[23] Therefore, it is logical to recommend polypectomy in infertile women with endometrial polyps as part of the management.
Congenital uterine abnormalities were found in 10.7% of the women. The main form of abnormality found was arcuate uterus followed by septate uterus. Although the actual incidence of congenital uterine abnormality within the general population is unknown, previous studies reported rates of 8%–10%[24],[25],[26] among women with infertility and recurrent miscarriages. Combined hysteroscopy and laparoscopy, also known as panendoscopy, is the gold standard in the diagnosis and surgical treatment of congenital uterine abnormalities. The surgery of choice is hysteroscopic resection which was done for our patients.
We found four cases of RFBs in this study causing secondary infertility. All the bones were found within the cavity and were successfully removed using the hysteroscope. Intrauterine RFB seen at hysteroscopy has been variously reported.[19],[27]
RFBs are usually suspected in cases where ultrasound shows a linear echogenic material within the cavity, especially in patients with a history of mid-trimester termination of pregnancy.
Sometimes, RFB is asymptomatic and found only during routine evaluation for infertility either with ultrasonography or hysteroscopy, as was the case with our patients. The diagnosis, therefore, requires a high index of suspicion, especially among women with a history of second-trimester pregnancy termination by dilatation and evacuation.
The mechanisms of infertility by RFBs are not clearly understood. However, it is postulated that retained bones close to the fundal area can trigger the local release of prostaglandins which may cause the prevention of blastocyst implantation.[24],[28] In addition, RFBs lying within the uterine cavity can act as IUCDs impairing fertility.[24]
Overall, the impact of RFBs on fertility appears to depend on whether the bones are completely embedded or lying freely within the uterine cavity. It seems there is evidence to suggest that the completely embedded bones do not affect fertility.[24]
Hysteroscopy is the gold standard in both the diagnosis and management of RFBs causing infertility as it allows the visualization of the uterine cavity under magnification and also provides the opportunity for the removal of the bones under vision. However, hysteroscopy can miss the bone pieces if the bones are embedded deeply within the endometrial-myometrial junction. Therefore, in cases with a highly suggestive clinical history and ultrasonographic picture in which hysteroscopy shows an empty cavity, there is a need for further evaluation.
Our study also found three cases of uterine perforation with incarceration of the omentum following two cases of dilatation and curettage for abortion and a case of uterine perforation by IUCD. There was associated chronic pelvic pain, dyspareunia, and dysmenorrhea in all cases.
The omentum was successfully teased out of the uterus with laparoscopy followed by laparoscopic closure of the myometrial wound in two cases while the remaining case required laparotomy as the omentum was involved with adhesions precluding laparoscopic management.
Cases of uterine perforation with subsequent incarceration of the omentum have been reported previously in the literature.[25],[26] The omentum acts as a tamponade limiting bleeding and walling off the site from pathogens. Most cases are recognized soon after the injury by consternation of clinical signs and symptoms including abdominal pain and vaginal bleeding. Sometimes, it goes unnoticed and discovered during evaluation for infertility.
| Conclusion | | |
Hysterolaparoscopy is an effective tool in the comprehensive evaluation and management of female infertility, particularly for the detection and treatment of peritoneal and intrauterine lesions that would otherwise have been missed by the routine investigative modalities.
Acknowledgment
We wish to acknowledge the contributions of the clinical staff that assisted in collecting the data from the patients and also participated during the procedures.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Obuna JA, Ndukwe EO, Ugboma HA, Ejikeme BN, Ugboma EW. Clinical presentation of infertility in an outpatient clinic of a resource poor setting, South East Nigeria. Int J Trop Dis Health 2012;2:123-31.  |
| 2. | Ikechebelu JI. Prevalence of gynaecological diseases in Nnewi, Nigeria. Niger J Clin Pract 2005;8:136-7. [ PUBMED] [Full text] |
| 3. | Karshima JA, Pam VC, Atim T, Abata PP, Reich MI. Indications for gynaecological consultation by women at a rural outreach centre in North-Central Nigeria. Int J Trop Dis Health 2014;4:696-712. |
| 4. | Okafor CO, Okafor CI, Okpala OC, Umeh E. The pattern of hysterosalpingographic findings in women being investigated for infertility in Nnewi, Nigeria. Niger J Clin Pract 2010;13:264-7. [ PUBMED] [Full text] |
| 5. | Ibekwe PC, Udensi AM, Imo AO. Hysterosalpingographic findings in patients with infertility in South eastern Nigeria. Niger J Med 2010;19:165-7. |
| 6. | Bukar M, Mustapha Z, Takai UI, Tahir A. Hysterosalpingographic findings in infertile women: A seven year review. Niger J Clin Pract 2011;14:168-70. [ PUBMED] [Full text] |
| 7. | Imo AO, Sunday-Adeoye I. Radiological assessment of the uterus and fallopian tubes in infertile women at Abakaliki, Nigeria. Niger J Clin Pract 2008;11:211-5. [ PUBMED] [Full text] |
| 8. | Odusoga OI, Oloyede OA, Adewunmi AA, Fakoya TA. Experience with the laparoscope in the evaluation of infertile women in Sagamu. Niger J Clin Pract 2002;2:127-9. |
| 9. | Ikechebelu JI, Mbamara SU. Should laparoscopy and dye test be a first line evaluation for infertile women in southeast Nigeria? Niger J Med 2011;20:462-5. |
| 10. | Otolorin EO, Ojengbede O, Falase AO. Laparoscopic evaluation of the tuboperitoneal factor in infertile Nigerian women. Int J Gynaecol Obstet 1987;25:47-52. |
| 11. | Kabadi YM, Harsha B. Hysterolaparoscopy in the Evaluation and Management of Female Infertility. J Obstet Gynaecol India 2016;66:478-81. |
| 12. | Zhang E, Zhang Y, Fang L, Li Q, Gu J. Combined hysterolaparoscopy for the diagnosis of female infertility: A retrospective study of 132 patients in china. Mater Sociomed 2014;26:156-7. |
| 13. | Vaid K, Mehra S, Verma M, Jain S, Sharma A, Bhaskaran S. Pan endoscopic approach “hysterolaparoscopy” as an initial procedure in selected infertile women. J Clin Diagn Res 2014;8:95-8. |
| 14. | Nayak PK, Mahapatra PC, Mallick J, Swain S, Mitra S, Sahoo J. Role of diagnostic hystero-laparoscopy in the evaluation of infertility: A retrospective study of 300 patients. J Hum Reprod Sci 2013;6:32-4. [ PUBMED] [Full text] |
| 15. | Boudhraa K, Jellouli MA, Kassaoui O, Ben Aissia N, Ouerhani R, Triki A, et al. Role of the hysteroscopy and laparoscopy in management of the female infertility: About 200 cases. Tunis Med 2009;87:55-60. |
| 16. | Mbaye M, Cissé ML, Guèye SM, Dièmé ME, Diouf AA, Guèye M, et al., Results of gynecologic laparoscopy in the Central University Hospital (CHU) of Dakar: Prospective series of 128 cases. J Obstet Gynaecol Can 2012;34:939-46. |
| 17. | Akinola RA, Akinola OI, Fabamwo AO. Pattern of genital tract abnormalities on hysterosalpingography in infertile patients in Ikeja, Nigeria. Niger Postgrad Med J 2009;16:31-4. |
| 18. | Adesiyun AG, Ameh CA, Eka A. Hysterosalpingographic tubal abnormalities and HIV infection among black women with tubal infertility in sub-Saharan Africa. Gynecol Obstet Invest 2008;66:119-22. |
| 19. | Okohue JE, Onuh SO, Akaba GO, Shaibu I, Wada I, Ikimalo JI. A 3 years review of hysteroscopy in a private hospital in Nigeria. World J Laparoscopic Surg 2009;2:26-9. |
| 20. | |
| 21. | Bosteels J, Kasius J, Weyers S, Broekmans FJ, Mol BW, D'Hooghe TM. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2013;1:CD009461. |
| 22. | Stamatellos I, Apostolides A, Stamatopoulos P, Bontis J. Pregnancy rates after hysteroscopic polypectomy depending on the size or number of the polyps. Arch Gynecol Obstet 2008;277:395-9. |
| 23. | Pérez-Medina T, Bajo-Arenas J, Salazar F, Redondo T, Sanfrutos L, Alvarez P, et al. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: A prospective, randomized study. Hum Reprod 2005;20:1632-5. |
| 24. | Cepni I, Kumbak B, Ocal P, Idil M, Aksu F. Infertility due to intrauterine residual fetal bone fragments. J Clin Ultrasound 2004;32:253-5. |
| 25. | Myounghwan K. Incarcerated omentum with tamponade effect in the uterine perforation scar after dilation and curettage: A case report. J Med Case 2014;5:204-7. |
| 26. | |
| 27. | Srofenyoh EK, Addison M, Dortey B, Kuffour PA. Intrauterine retained fetal bones as a cause of secondary infertility. Ghana Med J 2006;40:105-9. |
| 28. | Bahçeci M, Demirel LC. Osseous metaplasia of the endometrium: A rare cause of infertility and its hysteroscopic management. Hum Reprod 1996;11:2537-9. |
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for