Hysteroscopy overview

Benha University Hospital, EGYPT
Aboubakr ElnasharAboubakr Elnashar
Hysteroscopy overview

In 1869: Pantaleoni performed the first hysteroscopy, but it did not achieve routine gynecologic use due to its poor optic system. In 1970s: improvements in optics, distension media, light system and instruments. In 1980s and 90s: Office hysteroscopy without anesthesia or cervical dilatation Today: Many hysteroscopic procedures have replaced older, more invasive techniques.

Hysteroscopy as described by S.Duplay and S.Clado, 1898

The hysteroscope is a telescope (eyepiece, barrel, and objective lens) attached to a light source. Optical systems: Optical systems are either rigid or flexible.

Rigid hysteroscope The rigid hysteroscope is available in a range of diameters.
•3 mm (Office hysteroscopy). Cervical dilatation: Rarely required (paracervical block)
•>5 mm more specific surgical instruments through separate ports.
•8-10 mm continuous flow of media.

3 mm (Office hysteroscopy)
4.5 mm
Continuous flow
8 mm (Operative hysteroscopy)
Aboubakr Elnashar

Flexible hysteroscope (Office hysteroscope)
•The tip is flexible (120-160 degrees). The outer diameter: 3-3.7 mm
• Cervical dilatation: rarely required (Paracervical analgesia) Appropriate for the irregularly shaped uterus. Discomfort is less than rigid office hysteroscopy
•The view (ground glass quality) less than the rigid scopes .
•Biopsy Tubal catheterization

The Olympus HYF-XP flexible micro-hysteroscope Outer diameter of 3.1 mm: No anesthesia required 1.2 mm irrigation channel: Minor therapeutic procedures (e.g. biopsies)
Light cable
eyepiece
Channel port
Flexible sheath
Up/down lever
Bendable tip
Ventilation

Objective lens

Light Source:
•Halogen or xenon lamps.
•The power:100- 300 W.
•A fiber optic cable transmits light from the source to the endoscope.
•A videocamera: allow colleagues and the patient to participate and to make video recordings and training.

Distension media: It is necessary to distend the uterine cavity to obtain a panoramic view.
•Carbon dioxide.
•Low viscosity fluids: dextrose, saline, lactated Ringer’s, glycine, sorbitol. Saline offers advantages (shorter and less discomfort) over Co2 instillation
•High viscosity fluids: Dextran 70 (Hyskon)

Diagnostic
Abnormal uterine bleeding
Recurrent pregnancy loss
Unexplained infertility
Amenorrhea
Assisted conception
Abnormal HSG
Chronic pelvic pain
Postoperative evaluation
Pregnancy
Operative
•Endometrial biopsy
•Removal of IUCD
•Removal of polyps
•Myomectomy
•Lysis of IU adhesions
•Resection of uterine septum
•Endometrial ablation
•Tubal cannulation
•Tubal sterilization.
•Removal of retained products of conception

I. Abnormal uterine bleedingAbnormal bleeding Findings: 1. Endometrial hyperplasia. 2. Submucous/intramural fibroid: (Wamsteaker et al,1993) Type 0: pedunculated Type 1: < 50% intramural Type 2: > 50% intramural 3. Endometrial polyps. 4. Endometrial cancer. 5. IUCD

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Hysteroscopy should replace D&C in investigating postmenopausal bleeding (International Society for gyn endoscopy, 1989) It is the gold standard for diagnosis 1. Erratic menstrual bleeding 2. Failed medical treatment 3. TVS suggestive of intrauterine pathology e.g. polyp, fibroid (Grade B)

*Curettage or biopsy may miss: Small polyp Submucous fibroid Focal hyperplasia Focal endometrial carcinoma *Transvaginal ultrasound is accurate in excluding endometrial hyperplasia but is often unable to distinguish submucosal fibroids and polyps (New Zealand Guidelines Group : 1998-2002 Level A)

Advantages of hysteroscopy over D &C 1.The whole uterine cavity & the endocervix can be directly visualized 2.Very small lesions such as polyps can be identified & biopsed or removed 3.Bleeding from ruptured venules & echymoses can be readily identified & treated 4.The sensitivity in detecting intrauterine pathology is 98% (Loffer,1989) 5.Outpatient procedure 6. Treatment modality.

Disadvantages of hysteroscopy: 1.Cost of the apparatus 2.Lack of availability or experience 3. Hysteroscopy without biopsy is unreliable in D.D. between pre-malignant & malignant endometrium (Karlssson et al, 1994).

Cervical Polyp

)

II. Recurrent pregnancy loss. Anatomic:(10%) 1. Congenital uterine malformation. 2. Submucous fibroid 3. Cervical incompetence 4. Severe IU synechiae

HysteroscopicHysteroscopic classifications of IU adhesionsIU adhesions (March et al,(al,1978) Severe: >3/4 of uterine cavity involved; agglutination of walls or thick bands; ostialostial area & upper cavity occluded Moderate: ¼ - ¾ of uterine cavity involved; no agglutination of walls, adhesions only; ostialostial areas & upper fundusfundus only partially occluded. Minimal: <1/4 of uterine cavity involved; thin or filmy adhesions; ostialostial areas & upper fundusfundus minimally involved or clearminimally clear .

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Severe
Moderate

Classification of Mullerian anomalies (American Fertility Society, 1988)
Class I: Hypoplastic/agenic
Class II: Unicornuate
Class III: Didelphis
Class VI: bicornuate
Class V: Septate.
Class VI: Arcuate
ClassVII: DES related.

Septate uterus
.

Bicornuate uterus

Cervical incompetence: It is suspected if the resistance of internal os is < that of the cervical canal Opening of the int. os without passing through it . Internal os does not close after removing the optics (Traver et al., 2000)
Dilators or balloons to determine cervical resistance and/or HSG to measure the width of the cervical canal between pregnancies are neither sensitive nor specific.

III. 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.

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Cornual polyp

IV. Amenorrhea 1. Pregnancy test. 2. TSH &PRL. 3. Progestin challenge test: (MPA 5mgX5d or P in oil 100 mg /3dX 3) +ve: Anovulation -ve: E + P : -ve: outflow or uterine failure  HSG, hysteroscopy, IVP & laparoscopy. +ve: Ovarian failure or pituitary-hypothalamic dysfunction. 3. FSH: high: Ovarian failure. If 1ry: Karyotyping. If 2ndry: premature menopause Low or Normal: CT of Pituitary-hypothalamic region. . Abnormal: pituitary disease . Normal: hypothalamic dysfunction.

V. Abnormal HSG

VI. Assisted conception 1. After repeated implantation failure Abnormalities of the endometrium & organic IU pathologies are important causes of failed IVF-ET cycles (Dicker,1992)

2. Pre IVF evaluation: Hysteroscopy is an integral part of the pre IVF evaluation, to avoid unnecessary & expensive treatment failures (Shamma et al,1992; Shushan et al, 1999) Cost-effective analysis indicates that hysteroscopy, as a universal screening test even before the first IVF treatment , is well justified (La Sala et al, 1998)

VII. Postoperative evaluation= 2nd look hysteroscopy
•Hysteroscopic myomectomy
•Abdominal myomectomy
•Cesarean section
•Septum resection
•Asherman TT
•Endometrial ablation or resction
•Tubal reimplantation

Findings
•De novo or recurrent IU adhesions
•Incomplete myoma resection

VII. Pregnancy Rarely indicated
•IUD in pregnancy
•Embryoscopy
•Evaluate the disturbed pregnancy

Absolute
. Acute pelvic infection
Relative
. Active uterine bleeding
. Pregnancy
. Recent uterine perforation
. Invasive cervical cancer
. Inability to distend the uterus
. Cervical/vaginal infection
. Medical contraindication or intolerance of anesthesia

Thank You
Aboubakr Elnashar

Hysteroscopy overview

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