An intraoperative localization method and a stepwise surgical technique for hysteroscopic treatment of International Federation of Gynecology and Obstetrics type 3 fibroid.

OBJECTIVE

To present an intraoperative localization method and a stepwise surgical technique for hysteroscopic treatment of International Federation of Gynecology and Obstetrics (FIGO) type 3 fibroid without ultrasound guidance.

DESIGN

Video article.

SUBJECTS: Case 1 is a 34-year-old woman with complaints of menorrhagia and unexplained infertility and a FIGO type 3 myoma measuring 2.5 cm in diameter. Case 2 is a 35-year-old infertile woman with recurrent implantation failure and a FIGO type 3 myoma measuring <1 cm in diameter. Both women underwent hysteroscopic surgery at Peking University Third Hospital.

EXPOSURE: Preoperative localization was performed by the surgeon using transvaginal ultrasound to measure the distance from the fibroid center to the internal cervical os and the endometrial fundus on sagittal plane, and the distance from the fibroid center to the uterine cavity midline on the transverse plane. Intraoperative marking was then performed using hysteroscopic scissors, ensuring precise visualization and resection guidance. The fibroid was resected using the following stepwise technique: 1) the endometrium and pseudocapsule overlying the fibroid were incised with scissors to expose the myoma, 2) the fibroid was detached from the pseudocapsule using the body of the hysteroscope, 3) intravenous oxytocin was administered to promote myometrial contraction, facilitating the fibroid's gradual protrusion into the uterine cavity, and 4) the fibroid was resected using bipolar loop or cold forceps.

MAIN OUTCOME MEASURES: Complete resection of the FIGO type 3 fibroid as demonstrated by the absence of the targeted myoma. This was confirmed by immediate post-procedure hysteroscopic inspection and follow-up transvaginal ultrasound conducted 1 to 3 months postoperatively.

RESULTS

The FIGO type 3 fibroids were located without intraoperative ultrasound guidance, and were removed completely during a single surgery without excision of the endometrium surrounding the myoma. Postoperative transvaginal ultrasound in both patients revealed a continuous endometrial echo and no signs of intrauterine adhesions. In case 1, the patient subsequently reported complete resolution of her abnormal uterine bleeding, and she conceived spontaneously 3 months postoperatively. In case 2, the patient underwent transfer of two fresh cleavage-stage embryos and reported a clinical intrauterine pregnancy two months postoperatively.

CONCLUSION

We concluded that the intraoperative localization method, which includes preoperative ultrasound measurement with intraoperative scissors-tip marking, and is followed by a stepwise surgical technique for hysteroscopic treatment of FIGO type 3 myoma, is feasible and effective. This technique offers valuable benefits for precise localization and minimization of risk of damage to the endometrium. Hysteroscopic treatment of FIGO type 3 fibroids can improve symptoms of menorrhagia and also may improve reproductive outcomes in infertile patients with unexplained recurrent implantation failure. This technique was applied in clinical practice since June 2025 and both patients were from a larger cohort of infertile women with FIGO type 3 fibroid. Long-term follow-up data regarding postoperative reproductive outcomes currently are being collected and will be presented in future reports.