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Role of Hysteroscopy in InfertilityDr Rajesh Gajbhiye

Consultant Gynecologist and Laparoscopic Surgeon.Director Mauli Women’s Hospital,Nagpur

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Fertility ..Good ovum, Good SpermGood embryoPatent and functioning tubeGood Uterine cavityReceptive Endometrium

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Hysteroscopic Surgeon

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ContentDiagnostic HysteroscopySubmucous FibroidUterine septumIntrauterine AdhesionsEndometrial PolypProximal Tubal BlockPrior to ARTEndometrial Scratching

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IntroductionUterine factors can be found in only 2 to 3% of

infertile women, but intrauterine lesions are much more common in this setting (40–50%)

These lesions can compromise spontaneous fertility as well as reduce pregnancy rates in assisted reproduction .

Published observational studies suggest increased pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum, or intrauterine adhesions, which can be found in 10% to 15% of women seeking treatment for subfertility.

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Diagnostic HysteroscopyEvaluation of the uterine cavity is

a basic step in female infertility workup.

Transvaginal sonography Hysterosalpingography and are most commonly used for this purpose.

Hysteroscopy, however, is considered the gold standard for diagnosis of intrauterine lesions. 

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American Society for Reproductive Medicine (ASRM) Hysteroscopy is the definitive

method for the diagnosis and treatment of intrauterine pathology.

Costly and invasive method for uterine cavity evaluation, it should be reserved for further evaluation and treatment of abnormalities defined by less invasive methods such as HSG and sonohysterography [Fertility and

Sterility, vol. 98, no. 2, pp. 302–307, 2012 ]

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Diagnostic Hysteroscopy Normal 2D/3D USG/ HSG Unexplained infertility Uterine anomaly Prior to IVFRepeated IVF FailuresSuspected endometrial pathologyRecurrent abortionAbnormal uterine bleeding

In combination with laparoscopy and TVS Gives complete diagnosis

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Submucous fibroidAccording to the ASRM (2008) -

intracavitary myomas and submucous myomas having at least 50% of their volume within the uterine cavity.

In infertile women and those with recurrent pregnancy loss, myomectomy should be considered only after a thorough evaluation has been completed.

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Type0 & 1 hysteroscopic myomectomy

Types of submucous fibroids

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Meta-analysis-Submucous fibroidPritts et al. 2009 - studies

regarding the effect of fibroids on fertility and of myomectomy in improving outcomes.

They concluded that fertility outcomes are decreased in women with submucosal fibroids

Removal seems to confer benefit in terms of pregnancy rates.

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RCT-Submucous fibroid..

T. Shokeir, et al  Fertility and Sterility, vol. 94, no. 2, pp. 724–729, 2010

Prospective randomized matched control trial, 215 women with unexplained primary infertility and with ultrasonographically diagnosed submucous fibroids were enrolled.

Women in the study group had a better possibility of becoming pregnant after hysteroscopic myomectomy.

No difference in pregnancy rates was observed according to fibroid size, number, and location in both groups.

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Uterine Septum

Septal resection improves outcome in BOH

Its role in Infertility ?Current data does not give its

causal role

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MetroplastyMost studies of metroplasty for a septate

uterus combine women with recurrent miscarriage and infertility, and no study has been published that randomizes infertile women to treatment versus no treatment. For this reason controversy exists as to whether infertile women should undergo metroplasty

  C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty versus expectant management for women with recurrent miscarriage and a septate uterus,” Cochrane Database of Systematic Reviews, no. 6, Article ID

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Uterine Septum

Some recommended surgery and some not but randomized data is lacking.

Pabuccu et al found 41% spontaneous pregnancy rates after septal resection in patients with unexplained infertility with septum.

Long standing infertility with septum and otherwise unexplained.

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Hysteroscopic septal resection Microscissors, electrorosurgery, fiberoptic laser

energy.

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Metroplasty.Reproductive outcomes are improved

after hysteroscopic resection. Fedele et al evaluated the

reproductive outcome after hysteroscopic metroplasty in 31 women with infertility and 71 women with miscarriage, and reported a cumulative pregnancy rate of 89% at 36 months for patients with complete septum and 80% for those with partial septum

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Reproductive Outcome following Hysteroscopic Monopolar Metroplasty: An Analysis of 203 Cases

Ensieh Shahrokh Tehraninejad Int J Fertil Steril. 2013 Oct-Dec; 7(3): 175–180.

Evaluate the reproductive outcome of women with history of infertility or recurrent miscarriage following hysteroscopic septum resection

 Term deliveries increased significantly from 2.5 to 33.5%.

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Metroplasty

Laparoscopic guidance frequently is used during hysteroscopic metroplasty to reduce the risk of uterine perforation.

IUD insertion for 3 months with estrogenisation is only recommended for complete or wide septa.

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Intrauterine Adhesions

Intrauterine trauma resulting from vigorous endometrial curettage

After multiple myomectomy,septum resection.

Associated with RPL. The severity of adhesions may

range from minimal to complete

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ESGE Grade 3&4 require electrosurgical adhesiolysis and pregnancy rates are 20-40%

Post op IUD and estrogen is adminsitered after electrosurgical adhesiolysis.

Complication rates are also high

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T sahped uterusPts with TBNarrow constricted,T

shaped cavityDecreased

menstrual flow and amenorrhoea

Metroplasty fundal and lateral

Post op estrogen and IUD

Better pregnancy rates with IVF ET

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Cochrane reviewHysteroscopic myomectomy might

increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive.

Hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate J. Bosteels, “Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities,” Cochrane Database of Systematic Reviews, no. 1, Article ID CD009461, 2013

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Hysteroscopic tubal cannulation appears to be more effective than fluorosocpic guided canulation or open microsurgical repair or IVFET.

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Endometrial Polyps

Localized overgrowths of endometrium.

Polyps can distort the endometrial cavity, may have a detrimental effect on endometrial receptivity, and increase the risk of implantation failure .

The gold standard for diagnosis is hysteroscopy and hysteroscopic polypectomy remains the mainstay of management.

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Endometrial Polyp

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Endometrial polypsA recent Cochrane review tried to assess the effect

of hysteroscopic polypectomy on the results of intrauterine insemination (IUI). Apparently, the hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy compared to diagnostic hysteroscopy and polyp biopsy only (OR 4.4, 95% CI 2.5 to 8.0, and ).(J. Bosteels)

Implantation and clinical pregnancy rates were statistically significantly increased after hysteroscopic polypectomy in a group of women with recurrent implantation failure after IVF. I.( Stamatellos)

In conclusion, it appears that polypectomy prior to IUI or IVF (even I cases with previous implantation failure) increases the chances of pregnancy.

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For the infertile patient with a polyp, surgical removal isrecommended to allow natural conception or assisted reproductivetechnology a greater opportunity to be successful(Level A).

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Hysteroscopy prior to ARTA systematic review comparing the

outcome of IVF treatment performed in patients who had outpatient hysteroscopy.

The results of five studies showed evidence of benefit from outpatient hysteroscopy in improving the pregnancy rate in the subsequent IVF cycle.

F. Lorusso, O. Ceci, S. Bettocchi et al., “Office hysteroscopy in an in vitro fertilization program,”Gynecological Endocrinology, vol. 24, no. 8,

pp. 465–469, 2008.

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Hysteroscopy prior to 1st IVF

A systematic review and meta-analysis Jyotsna Pundir  et al

Reproductive BioMedicine OnlineVolume 28, Issue 2 , Pages 151-161, February 2014

Hysteroscopy in asymptomatic woman prior to their first IVF cycle was found to be associated with improved chance of achieving a pregnancy and live birth when performed just before commencing the IVF cycle.

Robust and high-quality randomized trials to confirm this finding are needed to further guide clinical practice.

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Currently, there is evidence that performing hysteroscopy before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles (Bosteels et al, 2010 and El-Toukhy et al, 2008).

However, recommendations regarding the efficacy of routine use of hysteroscopy prior to starting the first IVF treatment cycle are lacking.

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Hysteroscopy prior to ARTAnother recent study included 157 women

with a history of recurrent IVF failures (two or more) who underwent hysteroscopy (diagnostic or operative, as appropriate) to evaluate the endometrial cavity. Abnormal hysteroscopic findings were found in 44.9% of the patients in this study and 75 women (48.1%) became pregnant following hysteroscopy. Of these pregnancies, 36 occurred in women with corrected endometrial pathology, the majority of which was polyp.

P. Cenksoy et al Archives of Gynecology and Obstetrics, vol. 287, no. 2, pp. 357–360, 2013.

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Endometrial scratching improves IVF pregnancy rate

BMJ 2013; 347

Endometrial scratching involves causing intentional damage to the endometrium through biopsy or curettage.

An association between endometrial scratching and an increased chance of pregnancy was first described a decade ago, although the underlying mechanism remains unknown.

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The new study involved 158 women who had previously had unsuccessful courses of reproductive treatment and were taking an oral contraceptive pill directly before treatment. The women were randomly allocated to endometrial scratching with a pipelle de Cornier or a sham procedure 7-14 days before core ovarian stimulation was started.

Thirty nine of 79 women (49%) in the endometrial scratching group and 23 of 79 (29%) in the control group achieved a clinical pregnancy (risk ratio 1.83 (95% confidence interval 1.13 to 2.97)). There were 33 live births in the scratching group (42%) and 18 (23%) in the control group (risk ratio 1.7 (1.13 to 2.56)

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Endometrial scratching Improves the clinical pregnancy rate

in women undergoing assisted reproductive treatment, new research shows.

A Cochrane Library systematic review published in 2012 concluded that the technique doubled the chance of pregnancy and live birth after in vitro fertilisation (IVF) treatment but said that more research was needed.

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Conclusion Hysteroscopy in the management

of the infertile female remains under debate.

The procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women.

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Conclusion

The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome

observational studies suggest a benefit for resection of submucosal leiomyomas, adhesions, and endometrial polyps in increasing pregnancy rates.

More randomised controlled studies are needed to substantiate the effectiveness 

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ConclusionHysteroscopy before starting IVF

treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles

Endometrial scratching Improves the clinical pregnancy rate in women undergoing assisted reproductive treatment.

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