Normal saline should be used as it offers: advantages (shorter and less discomfort) over co 2 instillation.
New Zealand Guidelines Group : Level A
SHOULD HYSTERSCOPY BE DONE ROUTINLY IN THE EVALUATION OF INFERTILITY ? NO
Tests which have an established
correlation with pregnancy are:
1- Semen analysis
2-Tubal patency by HSG or laparoscopy
3-Mid luteal progesterone for the diagnosis of ovulation
They are the basic essential tests for diagnosis of infertility.
Routine Infertility Investigation ESHRE Capri workshop & National Guideline Clearinghouse 2000 RCOG Guidelines : Grade B Recommendation 1999
Routine Infertility investigation??!
Hysteroscopy should not be considered as a routine investigation in the infertile couple.
RCOG Guidelines : Grade C Recommendation 1999
Indications of Diagnostic Hysteroscopy for Reproductive Failure
Abnormal uterine bleeding
Suspected intrauterine pathology
When Hysteroscopy Should Be Done For Unexplained Infertility ?
At Laparoscopy ?
Before IVF ?
After Failed IVF ?
SHOULD HYSTEROSCOPY BE USED ROUTINELY AT THE TIME OF LAPAROSCOPY FOR . THE INVESTIGATION OF . INFERTILIY ?
El Sherbiny M, Medical J of Cairo Univ., Vol.65 No. 3, Sept. 1997 El Sherbiny M, The 7th Annual Meeting Of The Intern. Society for Gynecologic Endoscopy ,Sun City, South Africa;15:18 March,1998 Hysteroscopy done at laparoscopy time, has low complication rate, high degree of safety, minimal time 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
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.
` Unexplained infertility Cornual polyp cervical polyp HSG is free
Transvaginal hydrolaparoscopy in association with Minihysteroscopy
provided more information and was better tolerated than HSG in an outpatient infertility investigation.
Cicinelli et al . Fertil Steril 2001 Nov;76(5):1048-51 RCT (23 cases)
Indications of Operative Hysteroscopy for Reproductive Failure
Misplaced or embedded IUD
Tubal cannulation & Falloposcopy.
Priming With Misoprostol
Vaginal misoprostol prior to operative hysteroscopy facilitated the procedure and reduced complication
Y.F.Fong and K.Singh Evidence-based Obstet & Gynecol.,2000
Both saline infusion sonohysterography and hysteroscopy are well tolerated by women.
Saline infusion sonohysterography has a high failure rate but has a lower pain score than hysteroscopy.
Rogerson et al, BJOG 2002 Jul;109(7):800-4 RCT (117 cases) Transvaginal Sonohysterography Versus Hysteroscopy
Transvaginal Sonohysterography Versus Hysteroscopy
(TVSH) should be considered prior to hysteroscopy in women in whom intrauterine pathology such as submucous fibroids and polyps are suspected as diagnostic hysteroscopy can be avoided in up to 40% of women
Electro- resection of myoma by loop electrode loop electrode loop electrode Fibroid Resected tissue
Women who are diagnosed with submucous uterine fibroids and heavy or abnormal menstrual bleeding should be offered hysteroscopic resection .
New Zealand Guidelines Group : 1998-2002 Level C
Myomas can be removed effectively when:
Uterine size (depth )8-12 cm
>50% inside cavity.
< 5 Cm size
Hysteroscopic Resection Advanced Reproductive Care Inc : 2002
Endometrial Thinning Prior To Hysteroscopic Surgery For Menorrhagia
It improves both the operating conditions for the surgeon and short term post-operative outcome.
GRH analogues produce slightly more consistent endometrial thinning than danazol.
Sowter et al : 1998 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.
HSG : Filling defect Stellate & irregular, Commonly inhomogeneous HYSTEROSCOPY Confirmation Evaluation of the extent of the disease Intrauterine Synechiae
The American Fertility Society classification of intrauterine adhesions.1988. Extent of < 1/3 1/3 - 2/3 >2/3 Cavity Involved 1 2 4 Type of Filmy filmy & Dense Dense Adhesions 1 2 4 Menstrual Normal Hypomenorrhea Amenorrhea Pattern 0 2 4 Stage I (Mild) 1 - 4 Stage II (Moderate 5 - 8 Stage III (Severe) 9 - 12 Combined HSG & hysteroscopy & clinical
Intrauterine Synechiae Severe Moderate
It is controversial whether patients should:
Receive prophylactic antibiotics ?
Receive postoperative estrogen ?
Use of an IUD or Foley catheter ?
Intrauterine Synechiae: Postoperative Treatment Advanced Reproductive Care Inc : 2002