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.
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
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