Role of Hysteroscopy in Managing Infertility

THE ROLE OF
HYSTEROSCOPY IN
INFERTILITY MANAGEMENT
Dr Ezeike A.C, DR Lanre-Aremo B.O, DR Durojaiye K.W.
Dept of Obstetrics and Gynaecology
National Hospital Abuja

OUTLINE
 Introduction
 Epidemiology
 Evolution of Hysteroscopy
 The uterus/fallopian tube and fertility
 Role of Hysteroscopy in the Infertile patient
 Procedure/Instrumentation
 Basic Principles
 Hysteroscopy and the infertile patient
 Recent Advances
 Conclusion
2/29/2020THE ROLE OF HYSTEROSCOPY IN INFERTILITY MANAGEMENT
2

INTRODUCTION
 Hysteroscopy is the endoscopic examination of the uterine cavity
through the uterine cervix.
 Hysteroscopy is considered the gold standard in assessing the uterine
cavity.
 It has revolutionalized the diagnosis and treatment of intrauterine
pathologies and plays a crucial role in the management of infertility.
 One of the safest and most easily acquired gynaecologic skill in
developed countries (Bradley, 2004)
 In all societies of the world, infertility can be a distressing condition.
 Infertility is the inability of a couple to achieve pregnancy after one year
of regular, unprotected sexual intercourse.
3

INTRODUCTION
 The prevalence of infertility varies but is about 20% on the average.
 It is higher in certain parts of the world, Nigeria for instance where prevalenc
up to 25% has been reported.
 The female factors include uterine cavity pathology which may be congenita
acquired.
 Uterine factors may contribute up to 5% of causes of infertility.
 A Nigerian study found uterine factor in up to 30% of the infertile women.
4

EPIDEMIOLOGY
 Estimated number of women that had hysteroscopy was
197,800, 225,900 and 232,000 for the years 1994, 1995, 1996
respectively in USA.
 A total of 87 hysteroscopies were carried out at NISA
Premier hospital Abuja between Jan 2003 to Dec 2005.
 Eighty five patients (97.7%) presented with infertility.
5

EPIDEMIOLOGY
 In AKTH, from Jan 2011 to Dec 2014, 28 had diagnostic
hysteroscopy was, 5 underwent both laparoscopy and
hysteroscopy. Commonest indication was Asherman’s
Syndrome.
 Study among Doctors in S/South, 77.6% showed low
knowledge, 2.1% showed high knowledge while 20.3%
expressed moderate knowledge.
 Only 6.3% of the respondents have had a formal
training in hysteroscopy.
6

 Infertility in Nigeria- mainly secondary
 Infections lead to tubal and upper genital tract pathology:
STI’s, Post abortal sepsis, post-puerperal sepsis.
 10% < 30yrs- Infertility
 60% >40yrs – Infertility
 Socio-Economic factors: Poverty, Smoking, Alcohol intake,
Substance abuse.
EPIDEMIOLOGY
7

HISTORY AND EVOLUTION OF
HYSTEROSCOPY
 1807 Bozzini: First endoscope (light conductor)
 1869 Pantaleoni: First hysteroscopic examination in living patient
 1907 David: First contact hysterscope
 1914 Heinebery: System for irrigating uterine cavity
 1925 Rubin: CO2 for uterine distention
 1926 Seymour: Hysteroscope with inflow and outflow channels
 1927 Mikulicz Radecki and Freund: Biopsy-taking capacity cornual electro
coagulation
 1928 Gauss: Intra uterine photography
 1978 Newworth: use of resectoscope
 1980 Hamou: Microhysteroscope
 1981 Goldrath el al: Laser endometrial ablation
8

HISTORY/EVOLUTION
 Hysteroscopy did not become popular until the 1970s, when
technology afforded more practical and usable instruments
than before.
 The use of liquid distention media became routine by the
1980s, and many new hysteroscopic procedures, including
endometrial ablation, were developed.
9

HISTORY/EVOLUTION
 Over the past few decades, refinements in optic and
fiberoptic technology and inventions of new surgical
accessories have dramatically improved visual resolution and
surgical techniques in hysteroscopy.
 Initially used by urologists for transurethral resection of the
prostate, the resectoscope was modified for hysteroscopic
procedures, allowing for resection of intrauterine pathology.
10

HISTORY/EVOLUTION
 Many hysteroscopic procedures have replaced old, invasive
techniques.
 Now, as instruments become smaller than before, office
hysteroscopy is replacing operating-room
procedures(Versapoint and the Hysteroscopic Morcellator)
 One of the most recent hysteroscopic procedures is female
sterilization (Essure 2002)
11

THE UTERUS/FALLOPIAN TUBE AND
FERTILITY
12

ROLE OF HYSTEROSCOPY IN THE
INFERTILE PATIENT
 Can be Diagnostic, Therapeutic or Both.
 Plays critical role in evaluating Uterine factors mainly and some tubal
factors(proximal occlusion, hydrosalpinx)
 When compared with other methods of assessing the uterine cavity like
HSG and TVS-USS, it has more advantages(less false positive results)
13

INDICATIONS
Abnormal test findings (HSG, ultrasound scan)
Suspected mullerian abnormalities
Endometrial polyps
Submucosal fibroid
Intrauterine synechiae (Asherman’s Syndrome)
Foreign bodies e.g IUCD and Fetal bones
Proximal tubal occlusion
Hydrosalpinx
14

 Myomectomy
 Polypectomy
 Adhesiolysis
 Metroplasty
 IUCD/Foreign body removal
 Tubal cannulation/Occlusion
THERAPEUTIC PROCEDURES
15

INSTRUMENTATION/PROCEDURE
 Best performed in the postmenstrual phase(proliferative stage)
Can be an office or theatre procedure
 Distension Media: Co2, Normal saline, 5% Dextrose in water,
Glycine, Sorbitol, Mannitol, 32% Dextran-70
 Optics: Hysteroscope(Rigid or flexible) /Resectoscope
 Hand Instruments: Scissors, Graspers, Biopsy forceps
 Units: Hysteroflator, Endomat(Hysteropump), Electrosurgical,
Endovision system
 Endovision system; Camera, Light source, light cable, monitor
16

Hysteroscope with Hand
Instruments Resectoscope
17

Resectosocope with cutting loop
18

Single channel and Multichannel
Sheath
19

 FLEXIBLE HYSTEROSCOPE
 RIGID HYSTEROSCOPE
20

LAPAROSCOPY/HYSTEROSCOPY TOWER
21

FLUID DELIVERY SYSTEMS
ENDOMAT
PRESSURE SLEEVE
INFUSION
22

TISSUE REMOVAL SYSTEMS
Hysteroscopic Morcellator
Hysteroscopic Tissue
Remover
23

PROCEDURE
 Ensure power on all endoscopic units before induction of
anaesthaesia
 Conscious sedation, local, regional, or general anaesthesia.
 The patient is placed in the dorso-lithotomy position
 The vulva, vagina, and cervix are cleaned with an antiseptic solution.
 Bladder emptied( catheter to be retained in operative hysteroscopy)
 Bimanual examination
 Insert Sims vaginal speculum
 Cervix is grasped anteriorly with a single-toothd tenaculum
24

PROCEDURE
 The cervical canal is then gradually dilated to number 7 or 8 Hegar, depending
on the outer diameter of the instrument( for operative hysteroscopy)
 The hysteroscope attached to its light source and distension medium is
introduced atraumatically through the cervix into the uterine cavity with the
fluid running, under vision
 Take a panoramic view of the uterine cavity including both ostia, anterior,
posterior, lateral walls and fundus
 Once a complete evaluation of the uterine cavity has been performed, the
specific operative procedure(if necessary) begins
25

CLASSIFICATION OF FINDINGS
MAJOR
Structural change to the normal hysteroscopic
uterine anatomy; Mullerian malformation, Myoma,
Polyps, Adhesions
MINOR
Diffuse polyposis, Hypervascularization,
Strawberry pattern, Mucosal elevation, Endometrial
defects
26

PROCEDURE
BASIC PRINCIPLES
 Sensitivity almost 100% but interpretation is observer dependent
 Proper patient selection needed
 Treatment can be with either mechanical devices or powered
devices(electrosurgical or Laser)
 The more severe the lesion, the more likely a powered device will
be needed
 Damage to normal endometrium more likely with electrosurgical
devices
27

PROCEDURE
 In the event of perforation, higher risk of collateral damage with
electrosurgical devices
 Attention to fluid deficit
 Concomitant laparoscopy(with dimmed light) needed to
prevent/ reduce complications
 Complications more with severe lesions
 The larger the hysteroscope, the more likelihood the need for
anaesthesia
 Two staged procedure may be necessary
28

COMPLICATIONS
Usually results from faulty techniques or instruments and when contraindications are ignored.
 Complications due to the procedure
 Cervical trauma
 Uterine Perforation
 Haemorrhage
 Electrosurgical complications; Thermal injury to the endometrium or to viscera in the event
of perforation.
Prevention: Proper instrumentation, Concomitant laparoscopy, Always activate electrode
under vision
 Late complications
Uterine synachiae
29

COMPLICATIONS
Can be due to the procedure or due to the distension media
 Complications due to the distension media
 Co2 embolism
 Pulmonary oedema
 Hyponatraemia
 Encephalopathy
 Allergic reactions
 Coagulopathy
Prevention: Measurement of inflow/outflow, Distension pressure should be less than
100mmHg, Surgery should last less than 2 hours
30

HYSTEROSCOPY
AND THE
INFERTILE
PATIENT
31

SUBMUCOUS FIBROIDS
Mechanism of infertility in Submucous fibroids
 Physical impedance to sperm and embryo transport
 Altered uterine contractility
 Reduced levels of 1L10 and Glycodelin responsible for early implantation
and embryonic development
 Altered HOXA10, HOXA11 and BTEB1 gene expression leading to reduced
endometrial receptivity
 Reduction of both macrophages and uNK cells in the Endomyometrial
junction leading to defective decidualization
Evidence shows that fertility outcomes are decreased in women with
submucosal fibroids and that removal seems to confer benefit.(Pritts et al,
System. Rev. Fertil Steril. 2009)
32

HYSTEROSCOPIC VIEW OF A
SUBMUCOUS FIBROID
33

34

SUBMUCOUS FIBROIDS
 Hysteroscopic myomectomy is indicated for intracavitary
myomas and submucous myomas having at least 50% of
their volume within the uterine cavity.
 Treatment : Resection, Morcellation and Vaporization
 Hysterescopic scissors can also be used if the stalk is
narrow
 Resectoscope(Monopolar/Bipolar energy), Versapoint,
Laser, Morcelator
 Treatment with Gnrh agonists prior to hysteroscopy is
beneficial
35

Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD009461.
 Uncertainty remains concerning an important benefit with the
hysteroscopic removal of submucous fibroids for improving the
clinical pregnancy rates in women with otherwise unexplained
subfertility.
Recommendation: More research is needed to measure the effectiveness of
the hysteroscopic treatment of suspected major uterine cavity abnormalities in
women with unexplained subfertility or prior to IUI, IVF or ICSI
GRADE OF EVIDENCE; VERY LOW QUALITY
36

ENDOMETRIAL POLYPS
Endometrial polyps are benign, localized overgrowths of
endometrium.
Mechanisms of infertility
 Distortion of the endometrial cavity,
 Detrimental effect on endometrial receptivity
 Increased risk of implantation failure
Rx: Polypectomy
Mechanical( hysteroscopic graspers,scissors) or
electrosurgical devices
37

HYSTEROSCOPIC VIEW OF
ENDOMETRIAL POLYPS
38

Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.:
CD009461.
 The available low‐quality evidence suggests that the hysteroscopic
removal of endometrial polyps suspected on ultrasound in women
prior to IUI may improve the clinical pregnancy rate compared to
simple diagnostic hysteroscopy.
GRADE OF EVIDENCE: LOW QUALITY
39

UTERINE SYNAECHIAE
 Results from damage to the stratum basalis with adhesion formation,
bridging of denuded uterine walls and variable cavity obliteration
 Mechanism of Infertility: sperm migration disruption, tubal ostia
obstruction, impairment of implantation
 Treatment: By Using mechanical(Hysteroscopic scissors) or Powered
instruments(electric energy -Collins’s knife, Resectoscope or Laser –N-
YAG , KTP laser)
 Other methods.. Myometrial scoring, use of touhy needle
 Objective of Rx-removal of adhesion, restoration of anatomy, preventing
reoccurrence, restoration of menstruation and fertility
 Prognosis poorer for severe disease
40

HYSTEROSCOPIC VIEW OF UTERINE
ADHESIONS
41

CLASSIFICATION OF UTERINE ADHESIONS
42

 K. Roy, Jinee BaruahJai Bhagwan, SharmaSunesh ,KumarGarima
Kachawa, Neeta Singh
 The overall conception rate was 40.4% after hysteroscopic
adhesiolysis. The mean conception time after surgery was
12.8 months. There was no conception in patients who needed repeat
adhesiolysis
 The conception rate was higher (58%) in mild Asherman’s syndrome
compared to 30% conception rate in moderate and 33.3% conception
rate in severe cases.
43

 Prevention of reoccurrence: Foley catheter, IUCD and, barrier gels, human
amniotic membrane grafting, Eostrogens postoperatively
 There was insufficient evidence to determine whether there was a difference
between the use of a device or hormonal treatment compared to no treatment
or placebo with respect to term delivery or ongoing pregnancy rates (odds ratio
(OR) 0.94, 95% confidence interval (CI) 0.42 to 2.12; 107
44

SEPTATE UTERUS
 Recurrent miscarriage more likely
 Association with infertility unclear
 Comprehensive infertility evaluation necessary before reaching a conclusion to
treat
 Mechanism of infertility: Impaired implantation,associated endometriosis, tubal
anomalies,
 The main cause of impaired fertility in women with a septate uterus was
considered to be disturbed implantation.
 Recent evidence however shows that the septum consists of normal endometrium
and myometrium, and resembles the uterine wall
 RX; Hysteroscopic resection to create a uniform cavity(Metroplasty)
45

SEPTATE UTERUS
 Treatment: Rigid scissors, Resectoscope(Thin knife electrode) and
Fibreoptic Laser
 NICE GUIDANCE 2015: Current evidence on the safety of hysteroscopic
metroplasty of a uterine septum for primary infertility includes some
serious but rare complications. Current evidence on efficacy is
inadequate in quantity and quality. Therefore this procedure should only
be used with special arrangements for clinical governance, consent and
audit or research.
46

HYSTEROSCOPIC VIEW OF A SEPTATE
UTERUS
47

 In the cohort with deep uterine septum the live birth rate
increased from 3% (3 per 99 pregnancies) to 78.9% (30 per 38
pregnancies) after hysteroscopic metroplasty (P<0.001).
in the cohort with T-shaped uterus the live birth rate increased
from 8% (6 per 75 pregnancies) to 75.6% (28 per 37
after hysteroscopic metroplasty (P<0.001).
48

 No randomized controlled studies
 Nine comparative studies .Three of these studies showed a significantly higher
pregnancy rate in women with a septate uterus who were treated with surgery
(Gaucherand 1994; Pang 2011; Tonguc 2011), while six found no significant difference
between the groups (Heinonen 1997; Kirk 1993; Lin 2009; Maneschi 1991;
Sugiura‐Ogasawara 2013; Valli 2004).
 Conclusion: No evidence that hysteroscopic septum resection improves reproductive
outcome in women with a septate uterus and outweighs the possible complications of
the procedure.
49

HYSTEROSCOPY PRIOR TO ART
 Studies have shown benefit in patients with recurrent IVF failure
 Benefits have also been reported for patients undergoing first IVF treatment
 This is irrespective of findings at hysteroscopy
 The benefits appears to be greater if procedure is done in the cycle preceding the
IVF
Plausible Explanation
 Saline mechanically removes harmful anti-adhesive glycoprotein molecules on the
endometrial surface involved in endometrial receptivity
 Easier embryo transfer post hysteroscopy
 Mechanical manipulation of the endometrium may enhance receptivity by
modulating the expression of gene encoding factors required for implantation, such
as glycodelin A ,laminin alpha-4, integrin alpha-6 and matrix metalloproteinase-1
50

The Clinical Pregnancy Rate and Live Birth Rate were both
significantly higher in RIF patients with OH than RIF patients
without OH (CPR: RR 1.34, 95% CI 1.14–1.57, P < 0.05; LBR:
RR 1.29, 95% CI 1.03–1.62, P < 0.05)
CONC: Hysteroscopy may potentially improve pregnancy
outcomes in patients with RIF.
51

Reproductive BioMedicine Online (2014) 28, 151– 161
RESULTS: There was a significantly higher clinical pregnancy rate
risk, RR, 1.44, 95% CI 1.08–1.92, P = 0.01) and LBR (RR 1.30, 95% CI 1.00–
P = 0.05) in the subsequent IVF cycle in the hysteroscopy group.
RECOMMENDATION: Robust and high-quality randomized trials to
confirm this finding are needed to further guide clinical practice.
52

PROXIMAL TUBAL OCCLUSION
 Diagnosis usually by HSG/Laparoscopy
 High False positive rate for HSG(Sensitivity 65%/Specificity 83%)
 Possible causes of tubal occlusion: Spasm, stromal oedema,
intraluminal debris, intraluminal adhesions/polyps, endometriosis,
leiomyoma, fibrosis
53

PROXIMAL TUBAL OCCLUSSION
Range of procedures
 Selective tubal hydrotubation/dye test
 Tubal catheterization using coaxial wire
 Falloposcopy: Use of Guidewires and coaxial catheters to access the tube
via hysteroscopy or fluoroscopy,then a 0.5mm fibreoptic endoscope is
inserted
Advantage: Triage for patients with suspected tubal disease
Superior to proximal tubal reanastomosis via
laparoscopy/laparotomy
54

FALLOPOSCOPE
55

HYSTEROSCOPIC TUBAL CANNULATION
56

 Successful recanalization rate was 90.2% (46/51) per tube and 88.9% (24/27) per
In the 24 patients with successfully recanalization, six spontaneous pregnancies
and two intrauterine insemination-assisted pregnancies (8.3%) occurred within first
months of follow-up. All the eight (100.0%) pregnancies were intrauterine.
 Successful recanalization rate was 90.2% per tube and 88.9% per patient with a
conception rate of 33.3%.
 RECOMMENDATION: Women with only cornual obstruction should be considered
for laparoscopy-assisted hysteroscopic cannulation before assisted reproduction.
57

TUBAL OCCLUSION PRIOR TO ART
 Patients with hydrosalpinges have been identified as a subgroup with
significantly poorer outcomes of IVF-ET compared to tubal factor
patients without hydrosalpinges
 Evidence shows that Hydrosalpinges were associated with a reduced
chance of implantation and an increased risk of miscarriage
Mechanism Of IVF Failure With Hydrosalpinges
1. Mechanical washout of the transferred embryos through tubouterine
reflux of hydrosalpinx fluid,
2. Direct embryotoxic effect
3. Lower endometrial receptivity as an effect of disturbed cytokine and
integrin expression
58

TUBAL OCCLUSION PRIOR TO ART
 Salpingectomy/tubal
ligation has been shown to
improve outcomes
 Hysteroscopic occlusion is
now coming into relevance
 Essure® or Adiana®
microinserts can be used.
59

 All patients had successful placement of the Essure devices without any
complications. Proximal tubal occlusion was confirmed by hysterosalpingography in
9 out of 10 patients.
 A 40% ongoing pregnancy rate was achieved with 20% life births after one IVF cycle
and/or frozen embryo transfer.
 CONCLUSION: Proximal occlusion of hydrosalpinges with Essure devices before IVF
is a successful treatment for patients with a contraindication for salpingectomy.
60

 Clinical pregnancy per patient in Group A vs Group B (66.6% vs
64.3%, p= 0.8) were similar.
 Pregnancy outcomes after hysteroscopic placement of microinsert
for hydrosalpinx management prior to IVF were comparable to
those following laparoscopic tubal occlusion or salpingectomy.
Complications were uncommon and occur with both approaches
61

62
The ongoing pregnancy rates per patient according to the intention-
to-treat principle were 11/42 (26.2%) after hysteroscopic proximal
occlusion by intratubal devices (intervention group) versus 24/43
(55.8%) after laparoscopic salpingectomy (control group) (P = 0.008)
[absolute difference: 26.1%; 95% confidence interval (CI): 0.5–51.7,
relative risk (RR): 0.56; 95% CI: 0.31–1.03, P = 0.01].

FOREIGN BODY RETRIEVAL
An intrauterine foreign body such as a displaced
intrauterine device will interfere with fertility
Additionally, bony fragments from previous late first
trimester or second-trimester abortions can remain in
the uterine cavity acting as osteoblastic grafts.
Fertility can be restored by hysteroscopic retrieval with
graspers
63

RECENT ADVANCES
1. TROPHY Hysteroscope®
Allows a one stop uterine disgnosis and treatment(see and treat)
 TVS
 Fluid hysteroscopy with Trophy Hysteroscope(has a sliding operative
sheath) using the vagino-cervico atraumatic approach
 Repeat TVS(with the intracavitary fluid)
 Endometrial pathology-Rx
2. Versatile Bipolar Electrosurgery system(Versapoint®)
5F electrodes used in an office setting to treat a wide range of
pathologies
3.Enddosee®-Hand held, portable, flexible hysteroscope
2/29/2020
THEROLEOFHYSTEROSCOPYININFERTILITYMANAGEMENT
64

 TROPHY Hysteroscope
65

ENDOSEE®
66

Office Hysteroscopy set-up
67

FOOD FOR THOUGHT
At which specific step of the infertility work-up should hysteroscopy be performed in order to
maximize its beneficial effects on reproductive outcomes?
 At initial assessment?
 When an intrauterine abnormality is suspected by non-invasive methods?
 Prior to timed intercourse/IUI?
 Prior to first IVF/ICSI ?
 After one or more failed IVF/ICSI?
68

CONCLUSION
 An important challenge in the management of infertile patients is the
evaluation of uterine capacity for reproduction
 Though HSG and saline infusion sonography have proved valuable over the
years ,Hysteroscopy however retains its place as the Gold standard for
diagnosis of cervical and uterine pathology
 The simplification of hysteroscopic techniques now enlarges the spectrum for
ambulatory evaluation of the uterus
 Additionally modern therapeutic hysteroscopic procedures have replaced more
invasive therapeutic approaches via laparotomy and hysterotomy
 The use of hysteroscopy as a routine procedure in the infertility work-up is still
very much under debate
 Robust and high-quality RCTs are still needed before hysteroscopy can be
regarded as a first-line procedure in all infertile women
69

Role of Hysteroscopy in Managing Infertility

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