Effectiveness of Hysteroscopic Surgery on Pregnancy Rates in Patients with Primary infertility

4. Failure to achieve a clinical pregnancy after 12 months or
more of regular unprotected intercourse”.
(ICMART) and (WHO)
Failure to conceive after 12 months or
more of regular unprotected intercourse and The couple has
never conceived before.
Failure to conceive after 12 months
or more of regular unprotected intercourse after a prior
pregnancy or pregnancies have already occurred
 It affects between 60 and 80 million couples worldwide.
 In Egypt up to 15% of married couples suffered from
infertility

5.  There are many biological factors
of infertility such as:
 Ovulatory factors
 Utero-tubal peritoneal factors
 Sperm migration factors
 The male factor
 utero-tubal peritoneal factors are
present in 30% of couples

6.  Affect 2-3% of all women.
 Although they represent only 10%
to 15% of the causes of infertility
But uterine Abnormalities have
been found in 34% to 62% of
infertile women.
(Brown et al., 2000)

7. Evaluation of uterine cavity and treatment
of any existing abnormality have become
very important steps
in female infertility
workup

8.  Found in up to 50% of cases with
uterine abnormalities.
 Diagnosed in more than 30% of
primary infertile patients.
(Pansky et al., 2006; Sahu et al., 2012; Kaur et al., 2018)

9. The most common structural
uterine anomaly (35%).
Affects 1-2% of all women.
Nearly 40% of patients with
septate uterus have reproductive
failure and obstetrical
complications

10.  The most frequently diagnosed type
of gynaecological polyp (8-50%).
 Have a high prevalence rate among
infertile women (15-32%)
 Discovered during hysteroscopy in
16-26% of women with unexplained
infertility

11. Pathology examination of
hysterectomy specimens revealed
a prevalence of more than 75%.
Their prevalence is higher in
patients with infertility.

12. Fibroid Classification
Classical Clasification FIGO
(2011)
Submucosal - type 0 100% intracavity 0
Submucosal – type I >50% intracavity 1
Submucosal – type II <50% intracavity 2
Intramural In contact with endometrium 3
Intramural 100% intramural 4
Intramural Intramural but <50% subserosal 5
Subserosal Subserosal but <50% intramural 6
Subserosal Pedunculated 7
Other ( specify e.g cervical,
parasitic)
8

14.  US
 SIS
 HSG
 hysteroscopy
 MRI

15.  Uterine septa are often diagnosed during
an infertility evaluation
 Its incidence in infertile population is
higher than in the general population,
suggesting a link with infertility through
structural alterations
and poor blood supply
in the endometrium of
the septum

16.  Anatomical causes
 Distortion of the endometrial cavity
 Obstruction of the fallopian tubes.
 Functional changes
 Increased uterine contractility
 Impairment of the endometrial blood
supply
 Chronic endometrial inflammation
 Glandular atrophy and ulceration
affecting the endometrium

17.  Endocrine mechanisms
(Fibroids may induce paracrine
molecular effects on the adjacent
endometrium) e.g.
 Secretion of vasoactive amines
 Secretion of local inflammatory
substances.

18.  Mechanical obstruction of the tubal osti.
 Asynchronous hormonal response of the
endometrium
 Increased production of inhibitory factors
(glycodelin)  inhibit natural killer cell
function.

20.  Hysteroscopy is the ‘‘gold
standard’’ in the diagnosis of
intrauterine abnormalities.
 The frequency of unsuspected
intrauterine pathology has been
reported to be 40% by routine
hysteroscopy.

21. The goal of using hysteroscopy
 To identify structural abnormalities such as
polyps, myomas, or uterine septum.
 To treat any accessible abnormalities.
 To obtain a sample of the endometrium.

22. INDICATIONS OF HYSTEROSCOPY IN
INFERTILITY
 Suspected intrauterine pathology (polyps, submucous
leiomyomas, uterine septa, intrauterine adhesions)
 Uterine anomalies
 Unexplained infertility
 AUB
 Abnormal HSG.
 Planned intrauterine surgery
 misplaced or embedded foreign bodies
 Tubal cannulation
(Rafael, 2008)

24. Observational studies suggested that
operative hysteroscopy for
Will
increase
The odds of clinical pregnancy in
primary infertile women

25.  Trans-cervical resection of the septum
(TCRS) by hysteroscopy is a safe and
routinely used procedure for the
treatment of septate uterus in infertile
patients
 (TCRS) has many advantages
shorter operating time
less surgical trauma
fewer complications
Shorter hospital stay

26. Techniques
The common methods of TCRS include
(Micro-scissors, Laser and Electro-resection)
 Micro-scissors
o No need for cervical dilatation
o Don’t cause thermal damage to
surrounding tissues and organs
o Less incidence of water intoxication
Disadvantages: bleeding and relatively long
operating time

27.  Laser surgery
o Has a short operating time
o Good hemostatic effect and
o Can be used in all types of uterine
distention fluids.
Disadvantages: High cost, increase risk of
gas embolism
 Electro-resection
hysteroscopic electrosurgical excision of the
uterine septum is more widely accepted and
used method.

28. Hysteroscopic resection of
uterine septum and infertility
 Many studies reported that in women
with septate uterus and a history of
infertility  hysteroscopic septoplasty:
 Is a safe and effective procedure
 And resulting in increase in
pregnancy rates and live birth rates
(Nouri et al., 2010; Selvaraj et al., 2010; Esmaeilzadeh et al., 2014)

29.  Hysteroscopy remains the gold
standard for both the diagnosis
and treatment of endometrial
polyps

30. Techniques
 Grasping forceps for small solitary polyp
 Micro-scissors for small and multiple polyps
 A monopolar or bipolar resect-scope may
be used to remove larger or more
numerous polyps
 Hysteroscopic morcellating device for larger
polyps

31. Hysteroscopic polypectomy and
infertility
 Small intrauterine lesions such as
polyps, causing implantation failure,
show better clinical and obstetric results
after hysteroscopic polypectomy 
Particularly in patients with unexplained
infertility
 It can improve fertility, with pregnancy
rates ranging from 43% to 80%

32.  In general, submucous myomas
(types 0, 1, and 2) up to 4 to 5
cm diameter can be removed by
hysteroscopy.

34. Myomectomy Techniques
 Loop electrosurgical resection
The electrode is activated by low voltage
‘‘cutting’’ current to create “strips’’ of
myoma.
 Bulk electrosurgical vaporization
The electrode has a large surface-area and
activated with low voltage vaporizing current
to vaporize relatively large volumes of tissue
 Mechanical resection of leiomyomas
(hysteroscopic morcellation)

35. Concomitant performance of
laparoscopy or use of trans-abdominal
US is necessary for reduction the
chance of perforation.

36. Hysteroscopic myomectomy and
infertility
 Many studies concluded that
“[submucous] myomas lower fertility
rates and their removal enhances the
rates of conception and live births’’
(Pritts et al., 2009; Mavrelos et al., 2010; Shokeir et al., 2010)

37. Current Study

38.  Our study included 50 women in
reproductive age with primary
infertility.
 Inclusion criteria:
 Female patients with primary
infertility
 Age: childbearing period.

39.  Exclusion criteria:
 Contraindications to hysteroscopy: Marked
cervical stenosis, recent or current pelvic inflammatory disease, known
cervical malignancy, pregnancy, profuse uterine bleeding, or recent
uterine perforation.
 Patients with secondary infertility
 Previous cervical surgery.
 Patients with associated male factor
infertility

40.  Selection of patients was based on
Clear indications, complete medical
history, and physical examinations.
 Routine laboratory evaluations,
hormonal assay and semen analysis for
husbands had been carried out.
 They underwent hysteroscopic surgery
for resection of intrauterine septum,
resection of submucous myoma or
polypectomy.

41. Results & discussion

42.  After operative hysteroscopy fertility,
outcome of pregnancies and
improvement of any associated
complaints have been analyzed
according to 
 Type of intrauterine lesion
 And type of the main complaint
 No major complications or side effects
occurred.

44. Septum
22%
Fibroid
20%
Polyp
42%
Polyps + fibroid
16%
Distribution of the patients
according to type of pathology

45. • All patients were complaining of
primary infertility
• Most of them (70%) were complaining
of AUB (AUB only or AUB with dysmenorrhea)
• While 52% of them were complaining
of dysmenorrhea (Dysmenorrhea only or with AUB)
• And 18% of women were complaining
of both AUB with dysmenorrhea
• And in 30% of the patients, infertility
was the only complaint

46. 50
100%
35
70%
26
52%
9
18%
1
2%
InfertilityAUBDysmenorrhoeaAUB &
Dysmenorrhoea
hypomenorrhea
Distribution of main complaints
of the participants

47.  In current study AUB with infertility
were the main complaint
 This is similar to that mentioned in
other studies where (AUB) and
infertility were the most common
indications for operative hysteroscopy
(Camanni et al., 2010; Somigliana et al., 2007; Ghahiry et al., 2014).

48. Distribution of main complaints according to
type of pathology
 AUB was the commonest complaint in patients with
polyps (62%) and fibroids (88%).
 most patients of uterine septum group were
suffering from dysmenorrhea (54.5%), while only
one had hypomenorrhea.
 We noticed that dysmenorrhea was associated with
all intrauterine lesions.
 Also as we noticed intrauterine lesions (especially
septum and polyps) may be associated with
infertility without any associated symptoms

49. 16/18
88.8%
18/29
62%
4/11
36%
7/18
38.8%
10/29
34%
6/11
54.5%
2/18
11%
7/29
24%
1/11
9%
Septum ( N=11)Fibroids ( N=18)Polyps (No=29)
Distribution of main complaints according to type of
pathology
AUB dysmenorrhea infertility alone hypomenorrhea

50. 6
2
7
5
8
4
4
4
3
2
4
1
0
5
10
15
20
25
septum Myoma polyps Myoma + polyps
Infertility & hypomenorrhea Infertility & AUB & Dysmenorrhoea
Infertility & Dysmenorrhoea Infertility & AUB
Pure infertility

51. Reproductive outcome of the study
 During the first year of follow up 85% of
pregnancies occurred, with a mean surgery to
conception time span of 8.5 months.
 This short delay of conception has also been
observed by others
(Rosenfeld, 1986; Verkauf, 1992; Goldenberg et al., 1995).
 It is therefore strongly recommended that
patients attempt to conceive soon after the
procedure with no delay
 29 out of 50 patients (58%) achieved
pregnancy. Of those, 7 out of 29 patients
(14%) aborted, and live birth rate was 22
(44%).

53. 24%
47%
58%
65%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Szymanski et al
(2000)
Sanders (2006) Our study P-medina et al
(2005)
Spiewankiewicz et
al (2003)
Pregnancy rate in current study and some
other studies

54. Pregnancy rates in patients according to type
of hysteroscopic procedure
14
66%
6
54%
5
50%
4
50%
29
58%
0
5
10
15
20
25
30
35
Polypectomy Septum resection Myomectomy Polypectomy with
myomectomy
Total
Conception group (%)

55. Reproductive outcome in patients according to
type of hysteroscopic procedure
0
2
4
6
8
10
12
14
Polypectomy Septum resection Myomectomy Polypectomy with myomectomy
14
66%
6
54.5% 5
50% 4
50%
2
1
2 2
12
57%
5
45.5%
3
30% 2
25%
Pregnancies Abortions Live births

56. Distribution of patients relieved from
chief complains
27/35
77%
21/26
81%
7/9
77%
1
8
5
2
0
0
5
10
15
20
25
30
AUB dysmenorrhea AUB &
Dysmenorrhea
Others
Relieved Not Relieved

58.  In current study 21 patients (42% of the
participants) had endometrial polyps
 And more than 81% of patients who was
suffering from (AUB) due to polyp pathology
cured after hysteroscopic polypectomy
 This is similar to what mentioned in a study
that endometrial polyp is the most frequent
hysteroscopic finding in patient with (AUB)
who responds well to this treatment.
(Lasmar et al., 2008)

59.  In another study, more than 50% of
patients with endometrial polyps who was
suffering from (AUB) relieved after
hysteroscopic surgery. (Ghahiry et al., 2014)
 A third study reported that menstrual
pattern was normalized in 91% of patients.
(Stamatellos et al., 2008)

60.  As regards reproductive outcome, 14
women out of 21 got pregnant (66%), of
those women 12 gave live birth (57%)
 This was similar to a study where the
pregnancy rate after hysteroscopic
polypectomy was about 70%. (Ghahiry et al., 2014).
 Also other studies reported that
polypectomy had the best obstetrical
outcome. (Rama et al., (2006)
That supports the idea that 
Small intrauterine lesions such as polyps ,causing
implantation failure, show better results after
polypectomy

61. 61% 61%
65% 66%
70%
54%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Ayas et al (2011) Stamatellos et al
(2008)
Perez-Medina et al
(2005)
Current study Ghahiry et al
(2014)
Pregnancy rate (%) Live birth (%)

62.  In our study we followed 18 primary infertile
women with submucous uterine fibroids, who
were treated with hysteroscopic myomectomy
 AUB was the main complaint before
myomectomy (88%), and more than 76%
relieved after surgery.
 Hysteroscopic myomectomy appears to offer
long-term improvement for those who had
associated menstrual disorders; only 30% of
the patients in the current study had an
unsatisfactory outcome in this regard.

63.  As regards reproductive outcome,
pregnancy rate was 50% (n=9 of 18).
5 of these 9 women had live births
(55.5%) (28% of the 18 women),
while 4 patients (44.5%) aborted.
 It seems that endometrial damage and
intrauterine adhesions after
hysteroscopic myomectomy have
potential adverse effects on their
fertility as mentioned in other studies

64. 16.70%
28.7%
37.5%
47%
50%
52.8%
60.90%
62%
67%
77%
32.5%
40%
28%
36.1%
48.7%
50%
67%
61%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Preutthipan
et al (1998)
Hucke (1992) Vercellini et
al (1999)
Goldenberg
et al (1995)
Current
study
Varasteh et
al (1999)
Giatras et al
(1999)
Valle (1990) Donnez et al
(1990)
Corson et al
(1991)
Pregnancy rate Live birth

65.  In current study after hysteroscopic
metroplasty for uterine septum 6
patients of 11 achieved pregnancy
(54.5%),
 5 out of 11 had term delivery (45.5%).
 While 8 patients of 11 (72.7%)
improved completely from associated
symptoms

66.  Some authors concluded that the chances
of conception in patients with septate
uterus and infertility seem to be similar to
those of the general infertile population
either with or without septum resection
(Grimbizis et al., 1998).
 But other investigators challenged the
above mentioned opinion by reporting
favorable reproductive outcomes in infertile
patients after hysteroscopic septoplasty,
yielding results which are similar to those
in current study (Mollo et al., 2009; Tonguc et al., 2011; Shokeir et
al., 2011; Saygili-Yilmaz et al., 2002; Nouri et al., 2010).

67. 32%
38.5%
41%
53.8% 54% 54.5% 56%
57.9% 58% 58%
64%
69%
80%
88%
22%
34%
29.5%
47%
42%
45% 46%
52.6%
55%
38%
48% 49%
57%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pregnancy rate After septum resection Live births

69.  The presenting findings showed that 
(hysteroscopic resection of uterine
septa, myomectomy and polypectomy)
the pregnancy rate in
primary infertile women.
Therefore, it is suggested that in infertile
women with intrauterine lesions, operative
hysteroscopy is a confident and efficient
procedure resulting in a higher pregnancy rate
with better reproductive outcome
will increase

70.  Although a variety of studies
demonstrated that  the procedure is
well tolerated and effective in the
treatment of intrauterine pathologies,
there is no consensus on the
effectiveness of hysteroscopic surgery
in improving the prognosis of subfertile
women.

71.  More (RCT) and prospective studies are
needed
 Along with Consistent follow-up data
 To provide the highest level of
evidence and
 substantiate the effectiveness of the
hysteroscopic removal of intrauterine
uterine lesions and Various
postoperative treatments in infertile
women

72.  Although in the current study 
 24 months was an adequate time after
the procedures allowed, so that
subjects have ample time to attempt
conception and to give birth
 And this study focused on a specific
population “primary infertile patients”

73. further research studies should focus
on other specific populations with clear
indications  to draw reasonable and
meaningful conclusions about the
outcomes of operative hysteroscopy in
infertility.

74. Alaa Hassanin
M.B.B.Ch., M.Sc.
Obstetrics & Gynecology -Luxor