Hysteroscopy

What is Hysteroscopy?

Hysteroscopy is the direct visualization of the endometrial cavity using a thin fiber-optic instrument called a hysteroscope.

Why is it important to assess the uterine cavity?

Evaluation of the uterine cavity is one of the basic steps of infertility workup. Uterine abnormalities may be there by birth (congenital) or may occur later in life (acquired). Congenital uterine malformations like Septate uterus, Bicornuate or Unicornuate, or Acquired uterine lesions, such as uterine fibroids, endometrial polyps, intrauterine adhesions, or all of these, may cause infertility by interfering with proper embryo implantation and growth or may cause recurrent abortions.

Uterine abnormalities (congenital or acquired) are implicated in as many as 10% to 15% of couples seeking treatment. Moreover, abnormal uterine findings have been found in 34% to 62% of infertile women.

What are the different ways to assess the uterine cavity?

During the last decades, several methods including transvaginal ultrasonography (TVU), saline infusion sonography, and hysteroscopy, have been developed to assess the uterine cavity, with their own advantages and disadvantages.

Transvaginal ultrasonography is a widely available, simple, relatively cheap, non-invasive, and practical method to evaluate uterine pathologies. However, its relatively modest diagnostic value for uterine pathologies becomes challenging at times. Sonohysterography or saline infusion sonography (SIS) involves the distention of the uterine cavity with saline, in an attempt to provide better visualization. SIS offers better diagnostic value when compared to transvaginal ultrasonography. However diagnostic value for this modality is inferior when compared to hysteroscopy.

Hysteroscopy is the gold standard for the evaluation of the uterine cavity. It may be diagnostic or operative.

Diagnostic Hysteroscopy can diagnose much more precisely small intrauterine lesions that might affect fertility as compared to HSG or transvaginal ultrasonography. More than 1/3 of the patients interpreted as normal uterine cavities on ultrasound or HSG are found to have a uterine abnormality after diagnostic hysteroscopy, which might be a significant cause of reproductive failure. These women may be wrongly treated, or unnecessarily investigated, while their intrauterine lesion has been missed.

Operative hysteroscopy is used to correct an abnormal condition that has been detected during a diagnostic hysteroscopy in the same sitting, thus avoiding the need for a second surgery. Following abnormalities are corrected by operative hysteroscope:

• Endometrial Polyps: These are soft finger-like growths that develop in the endometrium usually due to a hyperestrogenic state. The true incidence of endometrial polyps is unknown. Many of them are clinically asymptomatic however they are found more frequently in the unexplained infertility population compared with fertile women. The possible role of these polyps in infertility is yet unclear, although follow-up on these women reveals improved reproductive outcomes after polypectomy. Thus it seems logical to propose polypectomy of all endometrial polyps among infertile women since even if small, they are likely to impair fertility. Removal of these polyps may enhance reproductive outcomes.
• Asherman syndrome (Bands of scar tissue in the uterine cavity, usually formed due to vigorous curettage after abortion). They may distort the cavity and may lead to impaired reproductive outcomes.
• Submucous myoma or fibroid The reported incidence of myomas is reported in infertile women in 1% and 2.4% without any obvious cause of infertility. Submucous and intramural myomas distort the cavity and alter uterine contractility or induction of inflammatory and vascular changes leading to less receptive implantation and pregnancy rates in women undergoing IVF. Hysteroscopy not only diagnoses these pathologies accurately, but also enables optimal assessment for possible myomectomy.
• Septum of the uterus It is a malformation of the uterus which is present since birth. If implantation occurs on the septum it may lead to abortion. Thus septum resection is indicated in cases of recurrent implantation failure.
• Removal of retained products of conception.
• Fallopian tube canalization along with laparoscopy for blocked tubes
• It is therapeutic in Abnormal uterine bleeding where no pathology is found
• Usually combined with laparoscopy for assessment of infertile couples.

How is a hysteroscopy performed?

It is a daycare surgery and does not require an overnight stay. Due to improved endoscopic developments, it can be performed reliably and safely as an office procedure, however, operative hysteroscopy is best done under general anesthesia. A 2.3-mm diameter continuous-flow endoscope is introduced via the vagina into the cervix and then into the uterine cavity. Distention of the uterine cavity is accomplished with a normal saline solution. This distention allows the complete visualization of the uterine cavity on the TV monitor.

During operative hysteroscopy, small instruments like scissors, biopsy forceps, and grasper electrocautery are used to treat the associated abnormalities.

When is it done?

Hysteroscopy is preferably done after the periods are over, usually day 6 – day 10 of the menstrual cycle as the endometrium is thin during this phase of the menstrual cycle and allows the best view of the inside of the uterus.

What are benefits of the hysteroscopy?

The pregnancy rates are said to improve even after diagnostic hysteroscopy as it releases certain endocrine factors which help in implantation. Significant unsuspected intrauterine abnormalities are found in 25% of patients with repeated failed in vitro fertilization and embryo transfer (IVF-ET) on hysteroscopy only. Shorter hospital stay, shorter recovery time, and less pain medication needed after surgery are a few advantages of hysteroscopy.

What are the risks and complications of hysteroscopy?

Hysteroscopy is a relatively safe procedure. However, as with any type of surgery, complications are possible. With hysteroscopy, complications occur in less than 1 percent of cases and they are usually mild and can include:

• Risks associated with anesthesia
• Infection
• Fever
• Uterine perforation
• False passage
• Heavy bleeding
• Injury to the cervix, uterus, bowel, or bladder
• Intrauterine scarring may occur later on due to overzealous curettage
• Reaction to the substance used to expand the uterus

While routine diagnostic hysteroscopy in the evaluation of the infertile woman is a debatable issue but one must keep in mind that this procedure today is a simple, fast, outpatient procedure with high success rates.