Normal saline should be used as it offer: advantages (shorter and less discomfort ) over CO2 instillation.
New Zealand Guidelines Group
CO 2 Fluid medium Technical expenditure Higher Low Risk of dissemination Very low Slightly higher Picture Very clear Clear Diagnosis of bleeding Limited Very good disorders Comparison of fluid and CO 2 distention media
The best advice is to have a set of instruments that can be modifiable for each specific situation, that is, small diagnostic hysteroscopes and sheaths for pure diagnostic evaluation that then can be changed with a larger diagnostic sheath containing an operating channel to accommodate biopsy or grasping forceps when needed.
Hysteroscopy done at laparoscopy time, has low complication rate, high requirement and adds little equipment & cost. Positive hysteroscopic findings were found in many cases (15 %) despite having normal HSG and no suggestive history of uterine lesion.
Operative office hysteroscopy without anesthesia: analysis of 4863 cases performed with mechanical instruments Simple instruments enable us to perform many operative procedures in an office setting with excellent patient satisfaction, provided that the indications are correct.
Bettocchi S, J Am Assoc Gynecol Laparosc. 2004 ;11:59-61.
Reference n % Lindemann-Mohr (1976) 1100 29 Siegler (1977) 77 39 Taylor-Cumming (1977) 68 44 Valle (1989) 142 62 Snowden et al (1984) 61 1.3 Keisler-Lancet (1986) 16 31.8 Fayez et al (1987) 194 24 Seinera et al (1988) 332 44.5 Dicker et al (1990) 284 30 Goldenberg (1991) 224 19 Kirsop et al (1991) 10 10 Golan et al (1992) 40 10 Normal HSG Vs abnormal hysteroscopy
In an IVF-ET program patients with normal hysterography but abnormal hysteroscopic findings had a significantly lower clinical PR, demonstrating the importance of performing hysteroscopy before IVF-ET.
When hysteroscopy is routinely performed prior to in vitro fertilization , a significant percentage of patients have uterine pathology that may impair the success of fertility treatment. Patient tolerance, safety, and the feasibility of simultaneous operative correction make office hysteroscopy an ideal procedure.
It is no more acceptable for a gynecologist to insert a sharp curette into a uterine cavity blindly to discover and remove suspected pathology than it is for an orthopedist to insert a curette into a knee joint blindly.