Fertility-enhancing Hysteroscopic Surgery

Stefano Bettocchi, M.D.; Maria Teresa Achilarre, M.D.; Oronzo Ceci, M.D.; Selvaggi Luigi, M.D.

Disclosures

Semin Reprod Med. 2011;29(2):75-82. 

In This Article

Abstract and Introduction

Abstract

Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyomata, intrauterine adhesions, and chronic endometritis, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. The position of hysteroscopy in current fertility practice is under debate. Although there are many randomized controlled trials on technical feasibility and patient compliance demonstrating 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. However, in patients with at least two failed cycles of assisted reproductive technology, diagnostic hysteroscopy and, if necessary, operative hysteroscopy is mandatory to improve reproductive outcome. Office hysteroscopy is a powerful tool for the diagnosis and treatment of intrauterine benign pathologies. It is a simple, safe, reproducible, effective, quick, well-tolerated, and low-cost surgical procedure, with no need for an operating room.

Introduction

The position of hysteroscopy in current fertility practice is under debate. Although there are many randomized controlled trials (RCTs) on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopy in improving the prognosis of subfertile women. The Royal College of Obstetrics and Gynaecologists[1] does not recommend hysteroscopy as an initial investigation unless clinically indicated, and it has categorized hysteroscopic treatment as a grade B recommendation in its evidence-based guidelines on fertility assessment and treatment. The European Society for Human Reproduction and Embryology has adopted a similar viewpoint.[2]

The uterus plays a role in sperm migration, embryo implantation, and fetal nourishment; congenital uterine anomalies, acquired uterine lesions, and systemic disease may affect such uterine functions precluding successful pregnancy. A receptive endometrium is morphologically and functionally primed for blastocyst attachment. Endometritis, endocrine abnormalities, immunologic factors, thrombophilias, congenital and acquired anatomic factors may contribute to implantation failure, resulting in recurrent pregnancy loss or infertility. Implantation failure is generally related to inadequate endometrial receptivity in two thirds of cases and abnormalities of the embryo in one third.[3] Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyomata, intrauterine adhesions, and chronic endometritis, have been reported in 21 to 47% of patients undergoing in vitro fertilization (IVF) cycles.[4]

The successful pregnancy outcome of patients undergoing advanced reproductive technology (ART) depends on several factors. Among these, embryo quality and uterine environment plays a major role in the achievement and further continuation of pregnancy. Evaluation of uterine cavity is recommended to screen for fibroids, polyps, adhesions, and uterine Müllerian abnormalities. These pathologies are commonly considered to have a negative impact on pregnancy outcome.[5–7]

Many clinicians prefer hysterosalpingography (HSG) as a first-line approach to evaluate intrauterine pathologies in infertile patients, and hysteroscopy is only required for confirmation of doubtful uterine pathology and for relevant therapy.[2] However, studies report that HSG has a false-positive rate of 15.6% and a false-negative rate of 35.4%.[8–10]

Hysteroscopic evaluation of uterine cavity for women with infertility has recently become a routine procedure. It enables direct visualization of the cervical canal and the uterine cavity, it offers assistance for the interpretation of uncertain findings from other diagnostic methods, and it permits the treatment of most benign intrauterine pathologies.[11]

Technological improvements, such as miniaturized hysteroscopes (continuous flow 4-mm operative hysteroscopes), mechanical, and electrical 5F instruments, and the use of correct techniques, enable us to perform many operative procedures in an office setting, without any analgesic pretreatment, assessing diagnosis and treatment in the same exam ("see-and-treat approach").[12,13]

There are no prospective, comparative RCTs on the role of hysteroscopy in the assessment of infertile women; there is currently insufficient evidence that systematic hysteroscopy, either in all infertile patients or before treatment, improves the outcome of ART. In our series of 866 consecutive patients who underwent office hysteroscopy (OH) prior to IVF, we found pathological conditions in 59.4% of the women. All these abnormalities were treated during OH. In the group of normal hysteroscopy, the implantation rate was 12.7%, with an ongoing pregnancy rate of 31.9%. In the group with normal hysteroscopy after OH treatment of uterine pathology, the implantation rate was 12.3%, with an ongoing pregnancy rate of 25.6%. These differences were not statistically significant. Moreover, we also compared outcomes in patients with two or more failed IVF cycles, with the same result. In this study the high incidence of intrauterine pathologies may suggest the introduction of the OH as a routine infertility examination, but no significant value was found in improving the pregnancy outcome.[14] In another recent study on 574 patients undergoing hysteroscopy before assisted reproduction, only eight had no symptoms, a normal ultrasound (US), but abnormal findings at hysteroscopy, and the authors concluded that screening by hysteroscopy was not cost effective.[15] Uterine anomalies are found, of course, in a certain percentage of patients, but the value of screening and treatment for them remains unproven. In particular, the importance of minor abnormalities, such as minor adhesions, small polyps, or myomas, which are asymptomatic and go unnoticed by US examination, is unproven. However, if a patient is symptomatic or intrauterine pathology is suspected from clinical and/or US examination, or after several failed treatment cycles, hysteroscopy is indicated. In this cases, compared with HSG, US, or saline US, hysteroscopy is considered the gold standard.[16,17]

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