Global Fertility services

Hysteroscopy is a valuable diagnostic and therapeutic modality in the management of infertility. For management of subfertility Hysteroscopy is best performed in the postmenstrual proliferative phase. Different media include CO2 gas, Sorbitol, glycine, Mannitol/Sorbitol mixture, 5% dextrose in water, or 32% Dextran-70. Endoscopes can range from 2 mm in size to 6.5 mm in size.

Absolute contraindications to hysteroscopy include a pelvic infection or endometrial cancer, and relative contraindications are pregnancy, excessive bleeding, cardiovascular diseases or severe vaginitis.

Complications (1–3%) include cervical laceration, uterine perforation, bleeding, reactions to the distention media, or anesthesia. Potential long-term complications include intrauterine scarring or tubal obstruction, as well as injury to contiguous organs.

Normal uterine cavity on hysteroscopy

Hysteroscopy should be performed after careful history and physical examination. We prefer to perform a diagnostic laparoscopy at the same sitting as hysteroscopy. The initial step at hysteroscopy is to identify the uterine cavity and ostia and to evaluate the right and left cornua, fundus, anterior/posterior walls, and lateral walls for specific lesions, as well as to evaluate the overall contour of the uterine cavity. The endocervical canal is also carefully evaluated on withdrawing the instrument. Uterine sounding is performed at the end of the hysteroscopy to minimize the creation of intrauterine artifactual lesions. Conditions that can be identified include adenomyosis, polyps, adhesions, fibroids, synechiae, congenital abnormalities and foreign intrauterine objects (e.g. IUD).

ENDOMETRIAL BIOPSY AND POLYPECTOMY
Endometrial biopsy and polypectomy are usually performed at the time of hysteroscopy. Biopsy is easily carried out with use of a biopsy instrument or grasper, or curettage of the cavity. This will identify polyps as well as luteal phase dysfunction, endometritis, or rarely an infertile patient's malignancy.

Hysteroscopic view of polyp.		Viewed on hysteroscopy

UTERINE MYOMAS
Sub mucous myomas can be identified at hysteroscopy. Myomas that have more than 50% of their volume inside the contour of the uterine cavity can be removed effectively with a resectoscope. Treatment of intrauterine myomas with GnRH agonists prior to hysteroscopy will reduce the myoma volume by approximately 50% in most cases. After treatment with GnRH agonists the uterine volume is reduced, the uterus will be hypoestrogenic and therefore more susceptible to perforation, even in the premenopausal woman. Resectoscopic myomectomy is a highly effective procedure, but fraught with potential hazards like uterine injury from the electrosurgical energy, perforation of the uterus, bleeding, infection, and most importantly, serious complication as a result of fluid overload. The upper range of uterine size when performing myomectomy should be approximately 8–12 cm of depth and only experienced surgeons should attempt a myomectomy larger than 5 cm. The advantages of hysteroscopic resection include the avoidance of laparotomy, uterine incision and creation of tubo-ovarian adhesions as well as the avoidance of a need for cesarean section in subsequent pregnancy. Overall, this is an excellent procedure if performed by skilled surgeons.

ASHERMAN'S SYNDROME
Intrauterine adhesions have been reported in 7% to 25% of infertile women. The pathophysiology involves damage to the stratum basalis and bridging of denuded uterine walls with variable cavity obliteration. Symptoms of intrauterine adhesions include hypomenorrhea or amenorrhea, cyclic pain, infertility and recurrent abortions possibly as a result of sperm migration disruption, tubal ostia obstruction, or impairment of blastocyst implantation.

Predisposing factors include an antecedent pregnancy; uterine trauma from curettage and endometritis (tubercular and others). Treatment involves removal or division of the adhesions with an endoscope, curettes, scissors, cautery, resectoscope, or nd-YAG laser. Prophylactic antibiotics, postop estrogen, or use of an IUD or Foley catheter is often used though their role remains controversial. We give antibiotics the night prior to surgery and for 3 days postop, along with estrogen for 4 weeks postop along with progesterone for the last week. Objectives of treatment are removal of adhesions and restoration of normal anatomy, with prevention of recurrence of adhesions, the restoration of menstruation and fertility. To achieve this, a gentle lysis of adhesions should be performed as is possible. In case of extensive adhesions, concomitant laparoscopic observation helps to reduce the risk of perforation.

CONGENITAL UTERINE ABNORMALITIES

Hysteroscopic resection of uterine septum

Congenital uterine abnormalities occur in about 1 to 2 per 1,000 women. As high as 5–10% of infertile women who are evaluated hysteroscopically are found to have congenital uterine abnormalities. The association of uterine anomalies with infertility is unclear. A comprehensive infertility evaluation is necessary prior to label a congenital uterine anomaly as a cause of infertility. Intravenous pyelogram should be performed to rule out associated renal anomalies. The American Fertility Society Classification of congenital uterine anomalies has grouped the anamolies as hypoplastic/agenic, unicornuate, didelphis, bicornuate, or septate. Laparoscopy at the time of hysteroscopy can be useful to delineate the external uterine contour for uterine anomalies. Hysteroscopic treatment of the uterine septum has the objective of creating a uniform triangular cavity. Electrosurgery at 30 watts can be used for septum resection. No treatment is needed for uterus didelphis or unicornuate uterus. The Strassman procedure may be indicated for a bicornuate uterus associated with pregnancy loss. Postoperative hysterosalpingogram at two months can evaluate the results prior to patients attempting pregnancy.

PROXIMAL TUBAL OCCLUSION
Proximal tubal occlusion can be diagnosed by HSG and confirmed at laparoscopy. Current technology also allows for hysteroscopic tubal catheterization and falloposcopy to help evaluate the fallopian tubes.Conditions associated with proximal tubal obstruction include muscle spasm or stromal edema, mucus plugs , intraluminal lesions such as adhesions or polyps, infectious lesions such as salpingitis or fibrosis, endometriosis and leiomyomas. Tubal catheterization will help confirm tubal occlusion, create tubal patency, and avoid major surgery for tubal repair and IVF if successful. It is a difficult and highly operator dependent procedure. Technical failures occur in at least 10% of the cases. The outcome of Hysteroscopic recanalisation / catheterization depends on the type of lesion. Thin non obstructive lesions have higher success rates and thick non obstructive lesions, dilated tubal stenosis and severe fibrotic processes have poor success rates.

The falloposcope is utilized through the hysteroscope and increases the ability to determine tubal status and diagnose pelvic disease. It is a system, using guidewires and coaxial catheters to canulate the tube and requires hysteroscopy or fluoroscopy for placement.

The above highlights the vast uses of hysteroscopy in management of subfertility.

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