1. Dr. Kaberi Banerjee
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
• MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
• MRCOG, London, UK
• Commonwealth Fellow in Reproductive Medicine, London UK.
• More than 8000 IVF, ICSI, Donor and Surrogacy Cases
• Awards:
• Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
• India Today Excellence Award in Field of Medicine 2015
• BL Jhaveri National Award in Medicine 2015
• Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
•MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
•MRCOG, London, UK
•Commonwealth Fellow in Reproductive Medicine, London UK.
•More than 8000 IVF, ICSI, Donor and Surrogacy Cases
•Awards:
•Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
•India Today Excellence Award in Field of Medicine 2015
•BL Jhaveri National Award in Medicine 2015
•Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.

3. Role of Hysteroscopy in
Difficult Embryo Transfers
Dr. Kaberi Banerjee,
Medical director
Advance Fertility and Gynae Centre, 6, Ring
Road, Lajpat Nagar 4, New Delhi 110024

4. Aim of Embryo Transfer
• Deposit the embryos inside uterine cavity
– To perform atraumatically
– To place in correct position to achieve proper
implantation

5. Difficult Embryo Transfer
• Criteria
– Problematic negotiation of cervical canal
– Require a firmer catheter
– Cause patient discomfort
– Require general anaesthesia
– Involve additional instrumentation such as stylet, tenaculum
– Time consuming

6. Difficult Embryo Transfer
• Causes
– Due to acute flexion or
deflexion or
anteversion/retroversion
b/w cervical canal and
uterus
– Adhesions d/t internal
trauma to endocervix or the
endometrium resulted from
previous surgeries, infection
or mock ET
– Cervical stenosis

8. Difficult Embryo Transfer
• Lower pregnancy rates
– Trauma to endocervix and
endometrium (bleeding)
compromises implantation
– Induces myometrial
contractions
– Carrying infection into
endometrial cavity

11. Hysteroscopy

12. Hysteroscopy
• Gold standard test
– For assessing uterine cavity and cervical canal
– Correcting the pathologies

14. Hysteroscopy
• Enhanced endometrial
receptivity secondary to
mechanical endometrial
injury

15. Hysteroscopy
• Irrigation of cavity with saline
mechanically removes harmful
anti-adhesive glycoprotein
molecules on endometrial
surface involved in endometrial
receptivity

16. Hysteroscopy
• May allow easier embryo transfer d/t
– Studying the course and morphology of cervical canal
– Passage of tip of hysteroscope through cervical canal
with the contemporaneous lysis of cervical adhesions

19. Cervical Canal Findings in Difficult
Embryo Transfer
• False passage in the cervix with acute
angulation
• Tortuous cervical canal with a fibrotic internal
os
• Severely fibrotic internal os
• Fibroid close to cervical canal

20. Hysteroscopic Procedures
• Consider correction of cervical canal
– Cervical canal shaving
– Refashioning of cervical canal with Versapoint
– Hysteroscopic evaluation and placement of a
Malecot catheter
– Hysteroscopic myosure morcellation
• Limitation – Only case studies/series available

22. Cervical canal shaving

24. Refashioning of cervical canal with
Versapoint

26. Malecot Catheter

29. Hysteroscopic myosure morcellation

30. ET Catheter (Outer)

31. ET Catheter (Inner)

32. ET Catheter Stylet

33. Labotect Catheter

34. AFGC Protocol
(Difficult ET Cases)
• If no previous H/o difficult ET
– P/S
– Require partial full bladder
– Afterload technique
– Use of Stylet
– Labotect Catheter
• If previous H/o difficult ET
– P/S examination & Mock ET
– Hysteroscopy
– ET under GA
– Labotect Catheter
• Hysteroscopic resection

35. Take home message
• Embryo Transfer – Most crucial step
• Difficult embryo transfer – Reduces pregnancy
rate
• Hysteroscopy helps in easier embryo transfer
– Helps in visualization of path of cervical canal
– Helps in negotiating through cervical stenosis
• Needs large number of RCTs for corrective
surgeries related to cervical canal