Infertilitede ofis histereskopisi

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  • 1. OFFICE HYSTEROSCOPY IN INFERTILITY Muammer DOGAN, MD.
  • 2. Hysteroscopy Instrumentation
    • Lockable cabinet
    • Telescope
    • Sheath system
    • Hysteroscope
    • Diagnostic
    • Operative
    • Resectoscope
    • Distention systems
    • Gas insufflator
    • Fluid delivery system
    • Light source and cable
    • Video cameras and monitors
  • 3. Sterilization of Instruments
    • It is not necessary for operators to wear scrub suits, gowns, masks, or caps to perform office hysteroscopy.
    • Sterile gloves are mandatory, and any instruments inserted into the uterus must be sterile.
  • 4. Sterilization of Instruments
    • Accessory instruments can be autoclaved or soaked in appropriate sterilized solutions.
    • Telescopes should never be autoclaved but should be sterilizing in the appropriate solutions.
  • 5. Hysteroscopes / Sheaths
    • Flexible (3-5 mm)
    • Adv. Minimal risk of trauma, ability to deflect the view manually
    • Disadv. Greater cost, inability to widen view or to magnify the image, inability to use the instrument
    • Rigid (4 mm) 0-30 degrees
    • Microhysteroscope (2.4-2.7 mm)
  • 6. Light Source
    • The optics of telescope 150 – W light source with flexible fiber optic cables
    • Halogen or xenon types bulbs for video cameras and monitors
  • 7. Distention media
    • CO2
    • Low flow, low flow insufflators
    • flow rates 100mL /m, press. 125mmHg,
    • Adv. Low cost, visibility good if no bleeding,
    • Disadv. Requires hys.insufflator,
    • Shoulder pain, uterine cramping,
    • Absorbed by blood and released thru pulmonary ventilation
  • 8. Distention media
    • Dextran 70 or Hyskon
    • ( High-viscosity fluid)
    • Adv. Visibility excellent even with bleeding,
    • Disadv. Expensive , caramelize when it dries, allergic reactions (anaphylactic shock), very thick and messy, do not use with continuous flow
  • 9. Distention media
    • Normal saline , Ringer’s lactate
    • ( Low-viscosity fluid)
    • Best with continuous flow, clear view, costly insufflators and pumps are unnecessary, bipolar procedures
    • Sorbitol, Glycine, Mannitol
    • ( Low-viscosity fluid)
    • Monopolar procedures
  • 10. Disten t ion Media:Saline Vs CO2
    • Normal saline should be used as it offer: advantages (shorter and less discomfort ) over CO2 instillation.
    • New Zealand Guidelines Group
  • 11. 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
  • 12. TIMING
    • It is preferable to perform hysteroscopy in the proliferative phase or immediately following a menstrual period.
  • 13. Hysteroscopy - Benefits
    • Direct visualization of any pathology
    • No X-ray exposure
    • Insertion under visualization decreases chance of perforation
  • 14. Indication of Office hysteroscopy for reproductive failure
    • Abnormal HSG
    • Uterine abnormalities (septae)
    • Unexplained uterine bleeding
    • Suspected intra- uterine pathology (polyps, myomas, adhesions, foreign bodies)
    • Pregnancy wastage
    • Unexplained infertility ?
    • Valle 1996.
  • 15. Controversial Indication
    • All infertile patients
    • Before IVF
    • Perimenopausal screening
    • Embryo replacement
    • Delivery of laser therapy
  • 16. Hysteroscopy Contraindications
    • Active PID
    • Active profuse uterine bleeding
    • Recent uterine perforation
    • Pregnancy
    • Cx Ca
    • Cardiovascular or systemic diseases
  • 17. Hysteroscopy Complications
    • Uterine perforation
    • Hemorrhage
    • Infection
    • Hypervolemia
    • Hyponatremic encephalopathy and cardiac asystole, arrhythmia
    • Hypercarbia, acidosis, gas embolism
  • 18. OFFICE HYSTEROSCOPY
    • Because of excellent drainage, the risk for infection with office hysteroscopy is exceedingly low.
    • ( 0.1%-2.8%)
  • 19. OFFICE HYSTEROSCOPY
      • The outpatient hysteroscopy failure rate is less than half (2%) with the mini-hysteroscope compared with the traditional 5 mm hysteroscope (5%).
      • De Angelis C Hum Reprod. 2003;18:2441-5 .
  • 20. OFFICE HYSTEROSCOPY
    • Office flexible minihysteroscopes (2.5 and 3.5 mm) can be successfully used in an office setting for gynecologic indications with high patient acceptance.
    • Ross JW. J Am Assoc Gynecol Laparosc. 2000 ;7:221-6.
  • 21. OFFICE HYSTEROSCOPY
    • Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.
    • Agostini A, J Am Assoc Gynecol Laparosc. 2004 ;11(2):245-7
  • 22. OFFICE HYSTEROSCOPY
    • Saline office diagnostic hysteroscopy offers at least all the advantages of the CO2 hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.
    • Perez-Medina T Int J Gynaecol Obstet. 2000 ;71:33-8.
  • 23. OFFICE HYSTEROSCOPY
    • 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.
  • 24. Preparation of the cervix
    • Vaginal misoprostol prior to diagnostic hysteroscopy reduced cervical resistance in nonpregnant women .
    • Fong&Sing. Evidence-based Obs&Gyn 2001;3:88
    • Dilatation, laminaria tents ??
  • 25. ANALGESIA ANESTHESIA
    • Pain, cramping, vagal reaction 10%
    • Para cervical block
    • In severe problem ;
    • Atropine 0.1-0.2 mg IM with/without
    • Ketorolac 30 mg IM
    • IV sedation (rarely)
  • 26. TECHNIQUE
    • CO2 ⇉ the telescope should be the first instrument through the canal
    • Inspection
    • Fundus ⇉ lower uterine segment ⇉ cervical canal
  • 27. TECHNIQUE
    • Analgesia-anesthesia-vaginal region cleaning,
    • No speculum- no tenaculum
    • (Vaginoscopical approach)
    • Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3: Supplement-S4.
    • Fluid distention media, continuous flow
    • Endomat; irrigation pressure=75-100 mm Hg, Flow=200-350 ml/min; suction= (-) 0.25 bar
    • 2.9 mm scopy (30 o )
    • Operating canal (1.6 mm)
    • (Operative office hysteroscopy)
  • 28.  
  • 29. ectocervix endocervical canal  internal os
  • 30. OFFICE HYSTEROSCOPY
  • 31. Intrauterine endometrial polyp
  • 32. Sub mucous myoma without intramural extension (type 0, ESGE classification). 
  • 33. Sub mucous myoma with typical stretched and dilated capsular vessels.
  • 34.  
  • 35.  
  • 36. OFFICE HYSTEROSCOPY
    • 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.
    • El Sherbinym 1998.
  • 37. OFFICE HYSTEROSCOPY
    • 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.
  • 38. 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
  • 39. Abnormal HSG Vs normal hysteroscopy
    • Reference n %
    • Goldberg et al-1997 40 20
    • Snowden et al-1984 61 10
    • Fayez et al-1987 85 30
    • Valle-1983 122 31-57
    • Keltz et al-1997 34 31
    • Golan et al-1996 464 55
    • Wang et al-1995 214 13
  • 40. OFFICE HYSTEROSCOPY
    • Hysteroscopy should not be considered as a routine investigation in the infertile couple.
    • RCOG Guidelines: 1999 Grade C recommendation .
  • 41. When hysteroscopy should be done for unexplained infertility?
    • At laparoscopy ?
    • Before IVF ?
    • After failed IVF ?
  • 42. Unexplained Infertility
    • Small endometrial polyp
    • Small cervical polyp
    • Adhesion at cornual cones
    • Cornual polyp
    • Endometrial atrophy or hyperplasia that may affect receptivity or implantation especially in ART
  • 43. OFFICE 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.
    • Shamma FN, Fertil Steril. 1992 Dec;58(6):1237.
  • 44. OFFICE HYSTEROSCOPY
    • D iagnostic hysteroscopy should be performed on all patients before they undergo IVF-ET.
    • La Sala GBFertil Steril. 1998 ;70:378-80.
  • 45. OFFICE HYSTEROSCOPY
    • 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.
    • Hinckley MD, JSLS. 2004 ;8:103-7.
  • 46. OFFICE HYSTEROSCOPY
    • Patients with normal hysterosalpingo-graphy but recurrent IVF-embryo transfer failure should be evaluated prior to commencing IVF-embryo transfer cycle to improve the clinical pregnancy rate.
    • Demirol A, Gurgan T. Reprod Biomed Online. 2004 ;8:590-4 .
  • 47. OFFICE HYSTEROSCOPY
    • Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.
    • Feghali J, Gynecol Obstet Fertil. 2003 ;31:127- 31.
  • 48. OFFICE HYSTEROSCOPY
      • The role of office hysteroscopy in menopause. Many operative procedures may be performed in the office setting with simple instruments, provided that correct indications are observed.
      • Bettocchi S, J Am Assoc Gynecol Laparosc. 2004 ;11:103-6.
  • 49. OFFICE HYSTEROSCOPY
    • Office hysteroscopy has become an important tool in the armamentarium of the gynecologist, especially in the evaluation of AUB, infertility , and pregnancy wastage
  • 50. OFFICE HYSTEROSCOPY
    • 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.