Case Report

A 33-year-old African woman presented with a 3-year history of primary subfertility. Her hormone profile and partner’s semen analysis revealed normal results. Transvaginal ultrasound scan suggested an intrauterine contraceptive device but the patient denied ever having an intrauterine contraceptive device fitted. Saline hysteroscopy was performed and revealed extensive endometrial ossification covering the whole endometrial cavity ( Figure 1 ). In all, 23 pieces of bone were removed. Some pieces remained to allow for endometrium to recover. Histology confirmed irregular pieces of woven bone in trabeculae. There was no evidence of chronic endometritis, atypia, or malignancy. Laparoscopy at this time showed normal pelvis and normal mobile fallopian tubes but bilateral proximal blockage. Repeat hysteroscopy was performed 6 months later and 15 further pieces of bone were removed ( Figure 2 ). There were 2 other pieces of bones that were embedded in the myometrium; 1 measured 1.25 cm. These were removed 2 months later hysteroscopically. An outpatient hysteroscopy 3 months later revealed normal uterine cavity with a small area of scarred endometrium.

Hysteroscopic view of endometrial cavity at time of first hysteroscopy, showing extensive ossification

Lloyd. Severe endometrial ossification. Am J Obstet Gynecol 2012.

Hysteroscopic view of endometrial cavity at time of second hysteroscopy, showing large bony fragment

Lloyd. Severe endometrial ossification. Am J Obstet Gynecol 2012.

No treatment was undertaken for the proximal tubal blockage as the patient wanted to proceed to in vitro fertilization. However, she became pregnant spontaneously, while waiting for treatment. At 20 weeks, fetal anatomy and growth appeared normal but the placenta was posterior and low lying. Repeat ultrasound at 36 weeks confirmed a posterior placenta previa minor and there was also a vasa previa. A healthy male fetus weighing 3.7 kg was delivered by elective cesarean section at 37+3 weeks. Her preoperative hemoglobin was 10.0 g/dL. A posterior placenta previa was found with a small area of accreta. Manual removal of the placenta aided by oxytocin infiltration at the placental bed (20 U of Syntocinon in 20 mL of normal saline). Vasa previa was confirmed. Estimated blood loss was 1.7 L. The postoperative hemoglobin was 9.8 g/dL after a 2-U blood transfusion. The patient made an uneventful recovery.