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Infertility Hysteroscopy

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  • 1. HYSTEROSCOPY FOR INFERTILE PATIENT An Evidence Based Approach Dr.Mohamed El Sherbiny MD Obstetrics&Gynecology Senior Consultant Damietta General Hospital Damietta Egypt
  • 2.
    • Cochrane library  .
    • Royal College of Obstetricians &Gynecologists (RCOG) Guidelines.
    • Journal of evidence based obstetrics and gynecology.
    • National Guideline Clearinghouse .
    • New Zealand Guidelines Group
    • PubMed
    Sources of EB for The Topic
  • 3. DIAGNOSTIC HYSTEROSCOPY
  • 4. RIGIDE OR FLEXIBLE ??
    • A rigid hysteroscope was superior to
    • a flexible hysteroscope for outpatient hysteroscopy
    Rudi Campo , Evidence-based Obstetrics & Gynecology Volume:3 Issue:3 Date:September 2001 p140-141
  • 5. Preparation of The Cervix
    • Vaginal misoprostol prior to diagnostic hysteroscopy reduced cervical resistance in non-pregnant women
    Fong& Singh Evidence-based Obstetrics & Gynecology : 3 Issue:2 Date:June 2001 p88-90
  • 6. Distension Media: Saline Vs Co 2
    • Normal saline should be used as it offers: advantages (shorter and less discomfort) over co 2 instillation.
    New Zealand Guidelines Group : Level A
  • 7. SHOULD HYSTERSCOPY BE DONE ROUTINLY IN THE EVALUATION OF INFERTILITY ? NO
  • 8.
    • 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
  • 9. Routine Infertility investigation??!
    • Hysteroscopy should not be considered as a routine investigation in the infertile couple.
    RCOG Guidelines : Grade C Recommendation 1999
  • 10. Indications of Diagnostic Hysteroscopy for Reproductive Failure
    • Abnormal hysterosalpingogram.
    • Abnormal uterine bleeding
    • Suspected intrauterine pathology
    • Uterine anomalies
    • Pregnancy wastage
    • Unexplained infertility
    Valle 1996
  • 11. When Hysteroscopy Should Be Done For Unexplained Infertility ?
    • At Laparoscopy ?
    • Before IVF ?
    • After Failed IVF ?
  • 12. SHOULD HYSTEROSCOPY BE USED ROUTINELY AT THE TIME OF LAPAROSCOPY FOR . THE INVESTIGATION OF . INFERTILIY ?
  • 13. 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
  • 14. 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.
  • 15. ` Unexplained infertility Cornual polyp cervical polyp HSG is free
  • 16. Mini-pan-endoscopic Approach
    • 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)
  • 17. OPERATIVE HYSTEROSCOPY
  • 18. Indications of Operative Hysteroscopy for Reproductive Failure
    • Polyp.
    • Submucous leiomyoma.
    • Uterine septa.
    • Intrauterine Adhesions.
    • Misplaced or embedded IUD
    • Tubal cannulation & Falloposcopy.
    Valle 1996
  • 19. 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
  • 20.
    • Uterine Polyp
    • Uterine Fibroid
  • 21.
    • 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
  • 22. 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
    New Zealand Guidelines Group : 1998-2002 Level A
  • 23. 36 38 Uterine Polyp Sonohysterography Hysteroscopy
  • 24. Electro- resection of myoma by loop electrode loop electrode loop electrode Fibroid Resected tissue
  • 25. Uterine Fibroid
    • 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
  • 26.
    • 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
  • 27. 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.
  • 28. Intrauterine synechiae
  • 29. HSG : Filling defect Stellate & irregular, Commonly inhomogeneous HYSTEROSCOPY Confirmation Evaluation of the extent of the disease Intrauterine Synechiae
  • 30. 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
  • 31. Intrauterine Synechiae Severe Moderate
  • 32.
    • 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
  • 33.
    • Division of the adhesions with:
    • The endoscope The curettes or scissors.
    • Resectoscopic cautery .
    • Neodymium-YAG laser
    Advanced Reproductive Care Inc : 2002 121 Intrauterine Synechiae: Operative Treatment
  • 34.
    • Restoration of menses: 70- 90%
    • Pregnancy rate : 60% - 90%.
    • Term pregnancy : 40- 80%
    • Poor for :
    • Severe disease,
    • Multiple procedures have been necessary.
    Intrauterine Synechiae : Prognosis Advanced Reproductive Care Inc : 2002
  • 35.
    • Perforation : 2%.
    • Infection : 2%.
    • Adhesion reformation :20-40%.
    • Placental complications :2-40%..
    Intrauterine Synechiae : Complications Advanced Reproductive Care Inc : 2002
  • 36.
    • CONGENITAL ANOMALIES
  • 37. Septate Uterus : Value of Hysteroscopy
    • Confirming the abnormality
    • Evaluating the uterine cavity capacity
    • Discarding other pathologic findings such as polyps, endometritis, hypertrophy
    • Guiding surgical aproach
    Traver et al. Infertility in the 3 rd Millennium Prague, 2000
  • 38. Resection of the Uterine Septum 121 Laparoscopic Guided Septum Collin's Electrode
  • 39. Abdominal Vs Hysteroscopic Resection of The Septum
    • Hysterscopic resection is preferable based on:
    • Cost
    • Morbidity
    • Anatomical outcome
    • Reproductive oucome
    Faize , Obstet.gynecol 68:399, 1986
  • 40. Proximal Tubal Obstruction (PTO)
  • 41. Proximal Tubal Obstruction
    • Fibrosis obliteration&SIN 40%
    • Endometriosis & Cornual polyp 10%
    • Cornual spasm 20%
    • Amorphous material 50%
    • Viscous secretions 30%
    • Mucosal agglutination
    • Stromal edema
    Valle 1996
  • 42. Oil-soluble Versus Water-soluble Media for H ysterosalpingography
    • Flushing of the tubes with oil-soluble media increases subsequent pregnancy rates in infertility patients.
    • It may flush t ubal &quot;plugs&quot; that are a cause of proximal tubal occlusion .
    • Clinicians should consider flushing the tubes with OSCM before contemplating more invasive therapies.
    Vandekerckhove et al ., July 1996 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.
  • 43. Tubal Catheterization
    • Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted
    RCOG Guidelines : Grade B Recommendation
  • 44. Tubal Catheterization Bilateral Cornual Block Amorphous material R. Ovary R. fimbria Cornual catheterization
  • 45. Falloposcope
    • Recently, the Food and Drug Administration has just given
    • the first approval for a falloposcope
    • in the United States.
    • The falloposcope will be utilized through the hysteroscope and will allows direct visualisation of the proximal segment and provides an atraumatic recanalisation . .
    Advanced Reproductive Care Inc : 2002
  • 46.
    • The risk to normal fallopian tubes through the use of falloposcopy is not clearly known but thought not to be significant..
    Falloposcope Advanced Reproductive Care Inc : 2002
  • 47. Thank You