3. In 1869: Pantaleoni performed the first hysteroscopy, but it did not achieve routine gynecologic use due to its poor optic system. In 1970s: improvements in optics, distension media, light system and instruments. In 1980s and 90s: Office hysteroscopy without anesthesia or cervical dilatation Today: Many hysteroscopic procedures have replaced older, more invasive techniques.
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6. The hysteroscope is a telescope (eyepiece, barrel, and objective lens) attached to a light source. Optical systems: Optical systems are either rigid or flexible.
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7. Rigid hysteroscope The rigid hysteroscope is available in a range of diameters.
•3 mm (Office hysteroscopy). Cervical dilatation: Rarely required (paracervical block)
•>5 mm more specific surgical instruments through separate ports.
•8-10 mm continuous flow of media.
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8. 3 mm (Office hysteroscopy)
4.5 mm
Continuous flow
8 mm (Operative hysteroscopy)
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9. Flexible hysteroscope (Office hysteroscope)
•The tip is flexible (120-160 degrees). The outer diameter: 3-3.7 mm
• Cervical dilatation: rarely required (Paracervical analgesia) Appropriate for the irregularly shaped uterus. Discomfort is less than rigid office hysteroscopy
•The view (ground glass quality) less than the rigid scopes .
•Biopsy Tubal catheterization
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11. The Olympus HYF-XP flexible micro-hysteroscope Outer diameter of 3.1 mm: No anesthesia required 1.2 mm irrigation channel: Minor therapeutic procedures (e.g. biopsies)
Light cable
eyepiece
Channel port
Flexible sheath
Up/down lever
Bendable tip
Ventilation
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13. Light Source:
•Halogen or xenon lamps.
•The power:100- 300 W.
•A fiber optic cable transmits light from the source to the endoscope.
•A videocamera: allow colleagues and the patient to participate and to make video recordings and training.
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14. Distension media: It is necessary to distend the uterine cavity to obtain a panoramic view.
•Carbon dioxide.
•Low viscosity fluids: dextrose, saline, lactated Ringer’s, glycine, sorbitol. Saline offers advantages (shorter and less discomfort) over Co2 instillation
•High viscosity fluids: Dextran 70 (Hyskon)
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25. Hysteroscopy should replace D&C in investigating postmenopausal bleeding (International Society for gyn endoscopy, 1989) It is the gold standard for diagnosis 1. Erratic menstrual bleeding 2. Failed medical treatment 3. TVS suggestive of intrauterine pathology e.g. polyp, fibroid (Grade B)
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26. *Curettage or biopsy may miss: Small polyp Submucous fibroid Focal hyperplasia Focal endometrial carcinoma *Transvaginal ultrasound is accurate in excluding endometrial hyperplasia but is often unable to distinguish submucosal fibroids and polyps (New Zealand Guidelines Group : 1998-2002 Level A)
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27. Advantages of hysteroscopy over D &C 1.The whole uterine cavity & the endocervix can be directly visualized 2.Very small lesions such as polyps can be identified & biopsed or removed 3.Bleeding from ruptured venules & echymoses can be readily identified & treated 4.The sensitivity in detecting intrauterine pathology is 98% (Loffer,1989) 5.Outpatient procedure 6. Treatment modality.
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28. Disadvantages of hysteroscopy: 1.Cost of the apparatus 2.Lack of availability or experience 3. Hysteroscopy without biopsy is unreliable in D.D. between pre-malignant & malignant endometrium (Karlssson et al, 1994).
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32. II. Recurrent pregnancy loss. Anatomic:(10%) 1. Congenital uterine malformation. 2. Submucous fibroid 3. Cervical incompetence 4. Severe IU synechiae
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33. HysteroscopicHysteroscopic classifications of IU adhesionsIU adhesions (March et al,(al,1978) Severe: >3/4 of uterine cavity involved; agglutination of walls or thick bands; ostialostial area & upper cavity occluded Moderate: ¼ - ¾ of uterine cavity involved; no agglutination of walls, adhesions only; ostialostial areas & upper fundusfundus only partially occluded. Minimal: <1/4 of uterine cavity involved; thin or filmy adhesions; ostialostial areas & upper fundusfundus minimally involved or clearminimally clear .
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36. Classification of Mullerian anomalies (American Fertility Society, 1988)
Class I: Hypoplastic/agenic
Class II: Unicornuate
Class III: Didelphis
Class VI: bicornuate
Class V: Septate.
Class VI: Arcuate
ClassVII: DES related.
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39. Cervical incompetence: It is suspected if the resistance of internal os is < that of the cervical canal Opening of the int. os without passing through it . Internal os does not close after removing the optics (Traver et al., 2000)
Dilators or balloons to determine cervical resistance and/or HSG to measure the width of the cervical canal between pregnancies are neither sensitive nor specific.
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40. III. Unexplained infertility
•Small endometrial polyp
•Small cervical polyp
•Adhesion at cornual cones
•Cornual polyp
•Endometrial dystrophies (atrophy or hyperplasia) that may affect receptivity or implantation especially in ART.
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46. VI. Assisted conception 1. After repeated implantation failure Abnormalities of the endometrium & organic IU pathologies are important causes of failed IVF-ET cycles (Dicker,1992)
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47. 2. Pre IVF evaluation: Hysteroscopy is an integral part of the pre IVF evaluation, to avoid unnecessary & expensive treatment failures (Shamma et al,1992; Shushan et al, 1999) Cost-effective analysis indicates that hysteroscopy, as a universal screening test even before the first IVF treatment , is well justified (La Sala et al, 1998)
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