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On the cusp of autumn color, APAGE-ISMIVS HIFU Series Webinars were featured by its third episode. HIFU Series Webinars are jointly organized by International Society of Minimally Invasive and Virtual Surgery (ISMIVS) and Asia-Pacific Association for Gynecologic Ebdoscopy & Minimally Invasive Therapy (APAGE), aiming to facilitate academic interactions in the new field of noninvasive surgery and promote the technology and education exchange among doctors from different countries and regions.

Episode 3 invited two eminent experts, Prof. Prashant Mangeshika, the Director of Center for Gynaecological Endoscopic Surgery and Institute for Research and Training in Minimally Invasive Surgery, Mumbai, and Prof. Amphan Chalermchokcharoenkit, the President of Thai Society of Gynecologic Endoscopists, to be in the chair, with four well-known speakers delivering in-depth insights on non-invasive therapy.

Dr. Hsin-Hong Kuo from Chang Gung Memorial Hospital at Linkou, Taiwan, mainly shared how to diagnose sarcoma through MRI before HIFU. He first introduced the classification and position of mesenchymal tumor in uterus, and said that it was hard to prognose leiomyosarcoma due to the similar symptoms with benign uterine myoma of bleeding, pelvic mass and pain. Then, he indicated that T2-weighted image of leiomyosarcoma was featured with irregular heterogenous and central hyper intense (necrosis/high cellularity), while T1 contrast image showing central necrosis with the evidence of invasion, with suspicious symptoms of rapid tumor growth (double size within 3-6 months), growing even with GnRHa and tumor growth after menopause.

Dr. Yen-Ju Sung also Chang Gung Memorial Hospital presented 3 cases of adenomyosis with infertility. One of the cases was a 37-year-old female who has suffered from infertility for 5 years due to adenomyosis, she received GnRHa for a month in June 2020, yet still got persistent symptoms. So in August 2020, she underwent HIFU treatment and conception with advice for about 6 month, after that, she became pregnant via IVF in April 2021 and is expected to deliver this December.

Prof. Chyi-Long Lee, the chairman of APAGE, discussed the management of adenomyosis in infertile patient. He first explained the pathogenesis of adenomyosis and indicated that ultrasonic evaluation of the type and extension of adenomyosis in the myometrium seems to be important to confirm the severity of symptoms and infertility. Then, he mentioned there were 5 treatment options including medical treatments, surgical options, radiologic, HIFU and combined therapy depend on the presence of specific symptoms, such as pain, abnormal uterine bleeding and/or infertility. He also indicated the cause of infertility and two major goals of treatment: improving the chance of pregnancy and ART outcome post adenomyomectomy or HIFU ablation. After elaborating several surgery videos of different therapy, Prof. Chyi-Long Lee concluded that segmented ART for adenomyosis patients seems to be the best option, and HIFU showed a safe and effective profile as a therapeutic management option for sub-fertile patients with adenomyosis.

Dr. Selva (Sevellaraja Supermaniam), a Consultant Obstetrician and Gynecologist at Mahkota Medical Center, Melaka, Malaysia, shared a clip of surgery videos in managing uterine fibroids and adenomyosis with HIFU, and indicated the standard procedures and useful skills of operation. During the Q&A part, for the question of how to position the focal zone, Dr. Selva and Prof. Chyi-Long Lee emphasized the importance of controlling the ultrasonic power and precisely positioning center zone and explained the usage of the water balloon.