Invited Lecture delivered in 23rd Annual Congress of ISAR (Indian Society for Assisted Reproduction) in April 2018 at Kolkata

1. Indications of Hysteroscopy
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (OBGY)
MRCOG (London)
Consultant, Genome: The Fertility Centre, Kolkata
Secretary, Website and Bulletin Committee, Bengal Obstetric and
Gynaecological Society (BOGS)- 2017-18
Managing Committee Member, BOGS- 2017-18
Member, Quiz Committee, FOGSI East Zone, 2018-19
Member, Food and Drug Committee, FOGSI, 2018-19
Peer Reviewer, BMJ Case Reports

2. Infertility- a big enigma?

3. Endometrium- Friendly or Hostile?
• Uterine factors- Found in 2-3% of the couples struggling to conceive
• can be present in 10-15% cases of “unexplained subfertility”

4. Hysteroscopy
• To confirm abnormal findings
• Apparently “Unexplained” Subfertility
• Previous IVF failure
• Symptomatic Patients
• Recurrent Pregnancy Loss
• Operative Intervention

5. Hysteroscopy to confirm
Abnormal Diagnostic Results

6. “Abnormal” Endometrium
• Polyp
• Endometrial Hyperplasia
• Adhesion
• Myoma
• Fluid
• Congenital Anomaly

7. Endometrial Polyp

8. Diagnosis of Polyp
1. TVS -investigation of choice where available (Level B).
2. The addition of color or power Doppler improves accuracy (Level B).
3. SIS and 3-D imaging improves the diagnostic capacity (Level B).
4. Blind D/C biopsy should not be used for diagnosis of endometrial
polyps (Level B).
5. Hysteroscopy- Gold Standard, polypectomy in the same sitting
AAGL Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

9. Polyps and Infertility
• can distort the endometrial cavity
• may have a detrimental effect on endometrial receptivity
• Frequently associated with obesity, diabetes, PCOS
(hyperestrogenism)
• Infertile women are more likely to be diagnosed with an
endometrial polyp (Level B)*
*AAGL Practice Guidelines for the Diagnosis and Management of Endometrial Polyps
10

10. Fibroids

11. AAGL Practice guidelines for sub mucous myomas :Level A
• HSG is less sensitive and specific
• TVS is less sensitive and specific than SIS/ Hysteroscopy/ MRI.
• MRI is superior in classification and realtionship of myomas with
serosa .
• Hysteroscopy- Gold standard for diagnosis and treatment

12. Intrauterine Adhesion

13. Diagnosis
• Hysteroscopy is the method of choice for diagnosis.
Level B
• HSG and SIS can be done in absence of hysteroscopy.
Level B
• MRI is not fully evaluated. Level C

14. ASRM Scoring for Intrauterine Adhesion
Look at... Size/description Score
Extent of
cavity
involved
<1/3 1
1/3–2/3 2
>2/3 4
Type of
adhesions
Filmy 1
Filmy and dense 2
Dense 4
Menstrual
pattern
Normal 0
Hypomenorrhoea 2
Amenorrhoea 4
Prognostic classification
Stage I (mild) 1–4
Stage II (moderate) 5–8
Stage III (severe) 9–12

15. Müllerian Anomalies

16. ESHRE/ESGE consensus on diagnosis of female genital anomalies, 2015
Asymptomatic Women-
• Screening
1. Gynaecological examination
2. 2D USS
• Further Evaluation-
3D USS
“Symptomatic” Women-
• 3D USS
Complex Anomalies-
(defined as having anatomical deviations in more
than one organ of the female genital tract)
• MRI
• Hysteroscopy and laparoscopy: in special centres
after thorough non-invasive evaluation and,
mainly, in the context of concomitant surgical
treatment of any discovered pathology.

17. Uterine Anomalies
• spontaneous miscarriage –
Septate > Bicornuate
• Recurrent pregnancy loss
• Malpresentation
• Fetal growth restriction
• Preterm labour
• Dysmenorrhea
• Association with Subfertility
Cause-effect relationship- ?

18. Septum, Infertility and Miscarriage

19. Hysteroscopy in “Normal”
Endometrium

20. Hysteroscopy in Unexplained Subfertility
• Semen Analysis
• HSG/ SIS/ Laparoscopy for tubal patency
• D21 Progesterone
Hysteroscopy should not be a part of routine evaluation
NICE- Fertility problems: assessment and treatment: Clinical guideline; February
2013

21. Unexplained Subfertility
• Where facilities are available, SIS together with 3D ultrasound can
offer a less invasive outpatient method to assess the uterine cavity
with accuracy similar to that of hysteroscopy
Brown SE, et al. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and
hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril
2000;74:1029–34.

22. Draz MH, El-Sabaa TM, El shorbagy SH. Saline infusion sonography versus hysteroscopy in the evaluation of uterine
cavity in women with unexplained infertility. Tanta Medical Journal. 2017, 45:155–159

23. • Women with unexplained infertility should be screened for possible
uterine cavity abnormalities.
• SIS is a simple and well-tolerated procedure that can be used as an
alternative technique for the evaluation of uterine cavity
abnormalities when Hysteroscopy is not available.
• However, Hysteroscopy is still considered the gold standard to
diagnose intrauterine pathology as it is more sensitive and more
accurate than SIS.
Draz MH, El-Sabaa TM, El shorbagy SH. Saline infusion sonography versus hysteroscopy in the evaluation of uterine
cavity in women with unexplained infertility. Tanta Medical Journal. 2017, 45:155–159

24. American Society for Reproductive Medicine (ASRM)
• Hysteroscopy is the definitive method for the diagnosis and
treatment of intrauterine pathology.
• Costly and invasive method for uterine cavity evaluation, it should be
reserved for further evaluation and treatment of abnormalities
defined by less invasive methods such as HSG and sonohysterography
Fertility and Sterility, vol. 98, no. 2, pp. 302–307, 2012
25

25. Routine Hysteroscopy before IVF?
INSIGHT Trial
• Routine hysteroscopy does not improve live birth rates in infertile
women with a normal transvaginal ultrasound of the uterine cavity
scheduled for a first IVF treatment.
• Women with a normal transvaginal ultrasound should not be offered
routine hysteroscopy.
• Smit JG, et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised
controlled trial. Lancet. 2016 Jun 25;387(10038):2622-9.

26. Hysteroscopy in Previous IVF
Failure

27. Bosteels J, et al. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without
other gynaecological symptoms: a systematic review. Hum Reprod Update 2010;16:1–11.
• Hysteroscopy in the cycle preceding a subsequent IVF
attempt nearly doubles the pregnancy rate in patients
with at least two failed IVF attempts compared with
starting IVF immediately (RR = 1.7; 95% CI: 1.5–2.0).

28. • 6 eligible studies comprising 4143 patients with RIF were included.
• OH (Office Hysteroscopy) vs No OH
• Hysteroscopy may potentially improve pregnancy outcomes in patients with RIF.
Cao H, You D, Yuan M, Xi M. Hysteroscopy after repeated implantation failure of assisted reproductive
technology: A meta-analysis. J Obstet Gynaecol Res. 2018 Mar;44(3):365-373.
OH vs No OH RR 95% CI P
Clinical Pregnancy Rate (CPR) 1.34 1.14-1.57 <0.05
Live Birth rate (LBR) 1.29 1.03-1.62 <0.05
CPR (OH vs No OH) RR 95% CI P
Asia 1.49 1.31-1.69 <0.05
Europe 1.08 0.93-1.26 0.291
Normal OH vs
Abnormal OH
RR 95% CI P
CPR 0.92 0.83-1.02 0.12
LBR 0.76 0.37-1.56 0.450

29. Hysteroscopy in Symptomatic
Patients

30. Symptoms
• HMB
 Not controlled by pharmacological measures with normal TVS
 Abnormal TVS- thickness/ polyp/ myoma
• IMB
 No apparent cause found
• PCOS
 HMB with thick endometrium
 No withdrawal bleeding with thick endometrium

31. RCOG Green Top Guidelines: No 33, November 2014; Polycystic Ovary
Syndrome, Long-term Consequences

32. Endometrial Hyperplasia
RCOG Green Top Guideline: No 67, February 2016; Endometrial Hyperplasia, Management of

33. Hysteroscopy in Recurrent
Pregnancy Loss

34. Anatomical Defects as a cause of RPL
• All women with RPL should be assessed for uterine anomaly
(≥3 first trimester loss, ≥1 second trimester loss)
• Septate Uterus- RPL in 1st TM
• Bicornuate/ Arcuate Uterus- RPL in 2nd TM
RCOG Green Top Guidelines No 17. April 2011. The Investigation and Treatment of Couples with
Recurrent First trimester and Second-trimester Miscarriage

35. Operative Hysteroscopy Enhancing Fertility
• Tubal Canulation
• Polypectomy
• Myomectomy
• Adhesiolysis
• Septum Resection

36. Proximal Tubal Block

37. Proximal Tubal Blockage (PTB)
• Accounts for approximately 15% of cases of tubal factor infertility
Salpingitis isthmica nodosa (SIN) 40%
Endometriosis
Cornual Polyp
}10%
Cornual Spasm 20%
Stromal Oedema
Tubal debris
Intraluminal adhesions
Viscid Secretion
}30%
• Suresh YN, Narvekar NN. TOG 2014;16:37–45.

38. Treatment of PTB
IVF vs Tubal Surgery
• Patient’s preferences
• Age
• Associated Fertility
Problems
• Cost, Expertise, Resources
• Risk of OHSS
Most of the
PTB
• Fluroscopic Selective
Salpingography
• Hysteroscopic Tubal
cannulation
SIN • tubal resection and
anastomosis of the diseased
inflammatory area- highest
success compared to tubal
catheterisation or expectant
management irrespective of
tubal patency
Suresh YN, Narvekar N. Role of surgery to optimise outcome of assisted conception treatments. The Obstetrician & Gynaecologist
2013;15 91–8.

39. Recommendations
• For women with proximal tubal
obstruction, selective
salpingography plus tubal
catheterisation, or hysteroscopic
tubal cannulation, may be
treatment options because
these treatments improve the
chance of pregnancy.
NICE Clinical guideline Fertility problems: assessment
and treatment

40. Hysteroscopic Polypectomy

41. Management algorithm for polyps
Annan JJ, Aquilina J, Ball E. The management of endometrial polyps in the 21st century. The Obstetrician & Gynaecologist 2012;14:33–38.

42. Evidences
43
Bosteels J, et al. Cochrane
Database Syst Rev. 2015 Feb
21;(2):CD009461.
IUI the hysteroscopic removal of polyps prior to IUI
increases the odds of clinical pregnancy
P´erez-Medina T, et al. Hum
Reprod 2005;20:1632–5
IUI Hysteroscopic polypectomy increases pregnancy rate
Stamatellos I, et al. Arch
Gynecol Obstet. 2008
May;277(5):395-9.
IVF In women in whom the only reason for subfertility
was endometrial polyps, hysteroscopic polypectomy
improved the rate of spontaneous conception
regardless of size or number of polyps
Ben-Nagi J, et al.. Reprod
Biomed Online 2009;19:737–
44
IVF Polypectomy improves implantation rate

43. AAGL Practice Guidelines for the Diagnosis and Management of
Endometrial Polyps
•Hysteroscopic Polypectomy is the Gold
Standard Treatment
•For the infertile patient with a polyp,
surgical removal is recommended to allow
natural conception or ART a greater
opportunity to be successful (Level A).

44. Hysteroscopic Myomectomy

45. SUB MUCOUS
HYSTEROSCOPIC
MYOMECTOMY
SUBSEROUS AND INTRAMURAL
<4CM
OBSERVE
4-7CM >7CM
LAP
MYOMECTOMY?
Optimum Management

46. Evidences
Pritts, et al. 2009 Meta-
analysis
Removal of submucous fibroids seems to confer
benefit in terms of pregnancy rates.
T. Shokeir, et al.
2010
RCT Women, with no other factors associated with
infertility, undergoing hysteroscopic myomectomy
had a better possibility of becoming pregnant.
Irrespective of fibroid size, number, and location
in both groups.

47. AAGL Practice guidelines for sub mucous myomas :Level A
• Removal improves fertility esp for type 0 and type 1 but remains low
as compared to normal uteri
• Cervical preparation can reduce trauma .
• Pre op use of GnRHa corrects anaemia

48. • Location of myomas
• Number of myomas
• Size of myomas
• Asymptomatic/symptomatic
• Associated adenomyosis/endometriosis
• Distortion of endometrium
• Previous failed IVF cycles
• Previous pregnancy losses
• Available expertise and resources
• Other factors affecting fertility
Before decision making

49. Hysteroscopic Adhesiolysis

50. AAGL Guidelines, 2017
• Hysteroscopic guidance is the method of choice with any tool. Level B
• No role of blind cervical probing or D/C. Level C
• Laparoscopy may be combined in cases of dense and lateral adhesions.
• Estrogens can be used to prevent recurrence.
• Reassessment of cavity after 2 to 3 cycles with HSG or office
hysteroscopy
• For women with IUAs who do not wish any intervention but still want to
conceive, expectant management may result in subsequent pregnancy;
however, the time interval may be prolonged. Level C.

51. Prognosis
• Restoration of menstruation- 70-90%
• Pregnancy Rate- 60-90%
(20-40% for severe disease and with recurrence)
• Term Pregnancy- 40-80%
• Pregnancy Complications- High
• Recurrence Rate- 30%
Advanced reproductive Care Inc 2002

52. Hysteroscopic Metroplasty

53. Cutter vs Keeper

54. Hysteroscopic Metroplasty For Septate Uterus –
A Meta-analysis Of 16 Published Series
Before After
Pregnancy 1062 491
Miscarriage 933 (88%) 67 (14%)
Preterm Delivery 95 (9%) 29 (6%)
Term Delivery 34 (3%) 395 (80%)
Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril.
2000 Jan;73(1):1-14. Review.

55. More Evidences
Mollo et al. Fertil
Steril 2009
Prospective
Controlled Trial
women with unexplained
infertility
Hysteroscopic resection of the septum
improves the pregnancy rate and live
birth rate
Ozgur et al.
Reprod Biomed
Online 2004
Retrospective
Study
Before IVF Incomplete septum removal improves
pregnancy, live birth rate and lowers
risk of miscarriage
Ensieh Shahrokh
Tehraninejad. Int J
Fertil Steril. 2013
Retrospective
Analysis
Subfertility, RPL Hysteroscopic metroplasty improves live
birth rate in both groups
Dural O, et al. JSLS,
2013
Retrospective
Analysis
Subfertility with past H/O
miscarriage
Hysteroscopic metroplasty improves live
birth rate, irrespective of the method
used
Fedele L, et al.
Hum Reprod, 1996
Observational
Study
Hysteroscopic Metroplasty
with residual septum <1
cm
Does not adversely affect reproductive
outcome

56. Cochrane Review, 2017
• Most studies of metroplasty for a septate uterus combine women
with recurrent miscarriage and infertility, and no study has been
published that randomizes infertile women to treatment versus no
treatment. For this reason controversy exists as to whether infertile
women should undergo metroplasty
C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty versus expectant management for
women with recurrent miscarriage and a septate uterus,” Cochrane Database of Systematic Reviews
2017, Issue 1. Art. No.: CD008576

57. “Prophylactic” Metroplasty
• May not increase fecundability, but may improve live birth rate
• Can prevent miscarriage and obstetric complications in IVF-pregnancy
• To be considered before IVF, especially if no other infertility factors
were present

58. Septum and RPL
RCOG Green Top Guidelines No 17. April 2011. The Investigation and Treatment of Couples with Recurrent First trimester and
Second-trimester Miscarriage

60. Take Home Message
•Routine hysteroscopy in unexplained subfertility- ?
•Routine hysteroscopy before 1st IVF- yet to be justified
•After failed IVF- hysteroscopy is definitely beneficial
•Intrauterine Pathology- should be addressed by
hysteroscopic diagnosis and treatment
•Hysteroscopic surgery increases chance of pregnancy
and live birth- spontaneously/ after IUI/ IVF