Authors would like to thank Mr. Pascal Lejeune for his technical support during all procedures.

The presented protocol is used for mares presented in the equine hospital and follows institutional animal care guidelines.
NOTE: Perform endometrial cysts photoablation before anestrus: heats observed in late July or August thus seem most reliable. Do not perform this procedure too late in the breeding season as it can limit the number of estruses available to treat a potential endometritis.
1. During the preceding estrus
<ol>
	<li>Perform a complete breeding sou...

<ol>
	<li>Kenney, R. M., Ganjam, V. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selected+pathological+changes+of+the+mare+uterus+and+ovary.">Selected pathological changes of the mare uterus and ovary.</a> Journal of Reproduction and Fertility. (23), 335-339 (1975).</li><li>Bracher, V., Mathias, S., Allen, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Videoendoscopic+evaluation+of+the+mare's+uterus:+II.+Findings+in+subfertile+mares.">Videoendoscopic evaluation of the mare's uterus: II. Findings in subfertile mares.</a> Equine Veterinary Journal. 24 (4), 279-284 (1992).</li><li>Kaspar, B., Kahn, W., Laging, C., Leidl, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometrial+cysts+in+the+mare.+1.+Post-mortem+studies:+occurrence+and+morphology.">Endometrial cysts in the mare. 1. Post-mortem studies: occurrence and morphology.</a> Tier&#228;rztliche Praxis. 15 (2), 161-166 (1987).</li><li>Leidl, W., Kaspar, B., Kahn, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometrial+cysts+in+the+mare.+2.+Clinical+studies:+occurrence+and+significance.">Endometrial cysts in the mare. 2. Clinical studies: occurrence and significance.</a> Tier&#228;rztliche Praxis. 15 (3), 281-289 (1987).</li><li>Mather, E. C., Refsal, K. R., Gustafsson, B. K., Seguin, B. E., Whitmore, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+fibre-optic+techniques+in+clinical+diagnosis+and+visual+assessment+of+experimental+intrauterine+therapy+in+mares.">The use of fibre-optic techniques in clinical diagnosis and visual assessment of experimental intrauterine therapy in mares.</a> Journal of Reproduction and Fertility. (27), 293-297 (1979).</li><li>Stanton, M. E., Mc Kinnon, A. O., Squires, E. L., Vaala, W. E., Varner, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Equine Reproduction Vol. 2. , 2665-2668 (2011).</li><li>Bracher, V., Mathias, S., Allen, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+chronic+degenerative+endometritis+(endometrosis)+on+placental+development+in+the+mare.">Influence of chronic degenerative endometritis (endometrosis) on placental development in the mare.</a> Equine Veterinary Journal. 28 (3), 180-188 (1996).</li><li>Tannus, R. J., Thun, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+endometrial+cysts+on+conception+rate+of+mares.">Influence of endometrial cysts on conception rate of mares.</a> Zentralbl Veterinarmed A. 42 (4), 275-283 (1995).</li><li>Pipers, F. S., Zent, W., Holder, R., Asbury, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+as+an+adjunct+to+pregnancy+assessments+in+the+mare.">Ultrasonography as an adjunct to pregnancy assessments in the mare.</a> Journal of the American Veterinary Medical Association. 184 (3), 328-334 (1984).</li><li>LeBlanc, M., Mc Kinnon, A. O., Mc Kinnon, A. O., Squires, E. L., Vaala, W. E., Varner, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Equine Reproduction Vol. 2. , 2620-2642 (2011).</li><li>van Ittersum, A. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+electrosurgical+treatment+of+endometrial+cysts+in+the+mare.">The electrosurgical treatment of endometrial cysts in the mare.</a> Tijdschr Diergeneeskd. 124 (21), 630-633 (1999).</li><li>Rambags, B. P., Stout, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcervical+endoscope-guided+emptying+of+a+transmural+uterine+cyst+in+a+mare.">Transcervical endoscope-guided emptying of a transmural uterine cyst in a mare.</a> Vet Record. 156 (21), 679-682 (2005).</li><li>Blikslager, A. T., Tate, L. P., Weinstock, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+neodymium:yttrium+aluminum+garnet+laser+irradiation+on+endometrium+and+on+endometrial+cysts+in+six+mares.">Effects of neodymium:yttrium aluminum garnet laser irradiation on endometrium and on endometrial cysts in six mares.</a> Veterinary Surgery. 22 (5), 351-356 (1993).</li><li>Bartmann, C. P., Stief, B., Schoon, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thermal+injury+and+wound+healing+of+the+endometrium+subsequent+to+minimally+invasive+transendoscopic+use+of+Nd:YAG-laser-and+electrosurgery+in+horses.">Thermal injury and wound healing of the endometrium subsequent to minimally invasive transendoscopic use of Nd:YAG-laser-and electrosurgery in horses.</a> Dtsch Tierarztl Wochenschr. 110 (7), 271-280 (2003).</li><li>Conley, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Review+of+the+reproductive+endocrinology+of+the+pregnant+and+parturient+mare.">Review of the reproductive endocrinology of the pregnant and parturient mare.</a> Theriogenology. 86 (1), 355-365 (2016).</li><li>Guzeloglu, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Expression+of+enzymes+and+receptors+of+leukotriene+pathway+genes+in+equine+endometrium+during+the+estrous+cycle+and+early+pregnancy.">Expression of enzymes and receptors of leukotriene pathway genes in equine endometrium during the estrous cycle and early pregnancy.</a> Theriogenology. 80 (2), 145-152 (2013).</li><li>Senger, P. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Pathways to pregnancy and parturition, 3rd edn. , (2015).</li></ol>

All authors are fully employed by Equine Clinic of Li&#232;ge University and have no conflicts of interest with any company trading one of the products mentioned above.

Hysteroscopy and laser photoablation of endometrial cysts is an easy procedure to reduce large intra-luminal cysts in the mare, as previously suggested14. Technically, this method is improved when performed on a mare in estrus. Inflating the uterus with sterile saline solution improved visibility when compared to air filling and continuous aspiration while performing the procedure.&#160; Small intra-parietal cysts (&#60;10 mm) are more difficult to reach and to treat. Moreover, treating these smal...

Endometrial cysts in mares were histopathologically described in the seventies by Kenney1. In the late eighties, the use of hysteroscopy and ultrasonography led to their clinical description and helped to understand their consequences on fertility2,3,4,5.
In the early stages, endometrial cysts have been associated with a degeneration of the endometrium now called endometrosis1,3,4,6,7,8 and it is currently accepted that small (&#60;1 cm) cysts are related to endometrial glands fibrosis when larger cysts are related to lymphatic dilatation6. These large cysts are the most likely to disturb equine embryo migration between day 6.5 and day 17, thus decreasing the fertility by impairing maternal recognition1,3,4,6,8. Endometrial cysts may also interfere with early pregnancy diagnosis, especially if they are round and have a size similar to that of an embryonic vesicle3,4,6,9 (see Figure 1). Thus, they can potentially increase the interval between two inseminations by delaying first embryo ultrasonography and twin gestation assessment (see Figure 2). Endometrial cysts may also interfere mechanically with fluid collection during uterine lavage performed to treat endometritis or to collect the embryo. Consequently, endometrial cysts have effects on observed mare&#8217;s fertility, with potential economic consequences in breeding farms.
Besides attempts to treat the underlying endometrosis10, endoscopically-guided focal treatments of cysts have been proposed. Electrosurgical cauterization has been described, but heat exposure could injure the endometrium around the cyst11. Aspiration of the cyst is only efficient if the secreting structure is no more active at the time of the puncture12. Laser irradiation with a 980 nm diode laser with a contact fiber seems to show smaller subsequent endometrial scars6,13. Improvement of laser devices and procedures6 now allows us to propose this safe and efficient technique in equine clinical practice. However, mare owners must be informed about the limits of this option. Photoablation of the cysts will increase embryo recognition in some mares, will advance the pregnancy diagnosis in some cases and could limit the negative mechanical effect of endometrial cysts on uterine lavage performed to treat endometritis or to collect embryos. However, it will never treat the concomitant underlying endometriosis or endometritis.
This report aims to describe an efficient procedure to perform hysteroscopy-guided diode laser cyst ablation in mares. Preparation and procedures will be practically described for a clinical application.

<table border="0" cellpadding="0" cellspacing="0" style="width:664px;" width="663">
	<colgroup>
		<col />
		<col />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">Butorphanol</td>
			<td style="width:121px;">Animedica</td>
			<td style="width:161px;">Morphasol 10 mg/mL</td>
			<td style="width:167px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">Detomidine</td>
			<td style="width:121px;">Dechra</td>
			<td style="width:161px;">Domidine 10 mg/mL</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">Endoscope</td>
			<td style="width:121px;">Olympus</td>
			<td style="width:161px;">Vet 170-10 SN2012729</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">Endoscope Vid&#233;o Tower</td>
			<td style="width:121px;">Olympus</td>
			<td style="width:161px;">CLE-E &#38; CV-E</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:214px;">Laser device</td>
			<td style="width:121px;">Wuhan Giga Optronics</td>
			<td style="width:161px;">Velas II-60B GA19-V3186</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">NaCl 0.9%</td>
			<td style="width:121px;">Baxter</td>
			<td style="width:161px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:214px;">P&#233;nicilline-proca&#239;ne</td>
			<td style="width:121px;">Kela</td>
			<td style="width:161px;">PENI-Kel 300.00 UI/ml</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:214px;">Ultrasonography</td>
			<td style="width:121px;">Aloka</td>
			<td style="width:161px;">Aloka 500 &#38; 5mHz transrectal probe</td>
			<td></td>
		</tr>
	</tbody>
</table>

endoscopy guided photoablation of endometrial cysts using a 980 nm laser with a contact fiber in mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

Surgeries were performed on mares having cysts with diameters over 15 mm. However, if other smaller cysts were also present, photoablation of the other cysts was attempted. Generally, these large cysts were at the bifurcation or the basis of the horns. However, some of them were present in the body of the uterus and were equally treated.&#160;
In our experience, intraluminal cysts are very easy to localize with the endoscope. Moreover, performing this procedure in saline solution increases the...

Watch this Scientific Journal Video about Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares at JoVE.com

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

Reducing the number of Endomentrial Cysts with laser and a hysteroscopy control can improve fertility by reducing the delay for pregnancy confirmation and improving embryo migration between day six and half and seventeen. Laser irradiation with a contact fiber, results in smaller subsequent endometrial scars. Performing this procedure in liquid environment, avoids smoke emission or foam production inside the uterus during the procedure.Diode laser is mainly used in overseas to treat upper airways pathologies. It could also be used for other pathologies, such as some skin disorders or for facilitated ankylosis. Before cyst ablation by laser, perform breeding soundness examination, including endometrial biopsy.To establish the prognosis and treat the underlying pathologies. It is impossible for placebo embryo transfer or exit. Demonstrating the procedure will be Pascal Lejeune and endoscopy specialized technician from our clinic.During the preceding Estrus, perform a complete breeding soundness examination of the mare, including an endometrial biopsy to ensure that the mare can potentially get pregnant after the procedure. During the preceding Diestrous, count, measure and map endometriosis in the uterus using transrectal ultrasonography, guided by palpation with a 7.5 or 5 MHz linear rectal probe and calipers on the screen in a contention stock. Intramuscularly administer 250 micrograms of Cloprostenol to induce estrus within two to three days, at day six to seven, post ovulation.Perform routine daily ultrasonography and cervix palpation to observe estrous signs. Including significant endometrial edema, antral follicle of 35 mm, or a softened and open cervix. Make sure that anyone entering the operating room is wearing eye protection.After emptying of the mare's rectum, wrap the tail and clean the vulva aseptically using Iodine-Povidone. To ensure easy manipulation and comfort of the mare, intravenously administer 10 mg/kg Detomidine and 0.1 mg/kg Butorphanol in the juggler vein with a 21 gauge needle. Install the embryo collection catheter through the cervix and inflate the balloon with 40 ml of air.Infuse the uterus 1.5 liters of sterile saline solution to inflate it, then deflate the balloon and remove the catheter. Pass the endoscope aseptically through the cervix within a sterile sleeve. Connect the 600 m quartz fiber to a diode laser operating at 980 nm.And set the power at 20 to 25 Watts in continuous mode. Pass the flexible quartz fiber via the biopsy channel of a 10 mm diameter video endoscope. Until 3 to 4 cm of free fiber can be identified on the screen.A minimum of 10 mm from the end of the fibers should be visible. Activate the laser to puncture the cyst. Ideally at its apex.In some cases, multiple punctures at various locations are necessary to achieve complete voiding. The cystic fluid is then passively drained out into the uterus. After the cyst lining has collapsed around the fiber, deploy the laser until the membrane shrinks.When acting in liquid medium, be sure that the fiber is in close contact with the cyst and verify the potential in the wound of cyst out punctured Perform transrectal ultrasonography of the uterus as many times as necessary during the procedure, to confirm that the endometrial cysts have disappeared. Collect the liquid infused in the uterus before the endoscopic procedure through a sterile cuffed catheter. Then flush the uterus with successive installations of one liter of sterile isotonic solution, until a clear liquid is collected.After the procedure, administer general antibiotic treatment intramuscularly twice a day for three days. Administer 20 IU of oxytocin intravenously at the end of the procedure. On the next day, perform transrectal ultrasonography of the mare uterus.Intraluminal free liquid is frequently observed. As long as free intraluminal fluid is observed by transrectal ultrasonography, and until the end of the heat, perform uterine lavage daily. Sometimes serum like limpid and yellow stained liquid is collected for several days.Perform transrectal uterine ultrasonography, during the following diestrus to confirm disappearance of endometrial cysts and the absence of intraluminal free fluid. This protocol was used to treat cyst with diameters over 15 millimeters. Photoablation of the smaller cyst was also attempted, if they were present.Generally large cysts were at the bifurcation or the bases of the horns. However, some of them were present in the body of the uterus and were also treated. Parietal cysts were more difficult to identify because of their location and their smaller size.Only the smallest parietal cyst were impossible to treat, but they do not interfere with the embryonic vesicles movements and are not easily confused with day 14 embryos. Never forget the associated underlying causes of infertility. Perform uterine swaps on biopsies, then treat and prevent these fertility dealing pathologies with Verve surgeries or uterine allergies.Multicentric studies about fertility observed before and after laser cyst ablation should be performed. However, semen quality, intimination timings and other external factors may induce extrinsic causes of variation.

endoscopy-guided-photoablation-endometrial-cysts-using-980-nm-laser

Research

JoVE Journal

Medicine

4.1K visualizações.  Liège University. Reducing the number of Endomentrial Cysts with laser and a hysteroscopy control can improve fertility by reducing the delay for pregnancy confirmation and improving embryo migration between day six and half and seventeen. Laser irradiation with a contact fiber, results in smaller subsequent endometrial scars. Performing this procedure in liquid environment, avoids smoke emission or foam production inside the uterus during the procedure.Diode laser is mainly used in overseas to treat up...