The Role of Office Hysteroscopy in Infertility Management

The use of ultrasound in combination with hysteroscopy on infertility assessment in the office setting has brought more advantages than their individual use. Ultrasound can be used to reveale not only the structural abnormalities (fibroids, adenomyosis, ovarian and tubal mass, polyps, uterine malformation), but also to assess follicle growth, ovulation, endometrial receptivity, and tubal assessment. Office hysteroscopy has the diagnosis and at the same time treatment capacity, especially in subtle pathologies such as internal ostium stenosis, small and micropolyps, cavity deformation, and also for tubal patency. The combination of these two modalities is beneficial in several situations: guiding the hysteroscopy procedures during complicated intrauterine pathologies to prevent uterine perforation and to evaluate the result, ultrasound assessment after hysteroscopy procedures to assess uterus as in saline infusion sonography, to evaluate tubal patency by looking at the addition of fluid in the Douglas pouch and to determine any adhesion between the uterus, both adnexa and surrounding organ by the aid of the fluid as contrast media. By combining these two office modalities, diagnosis and management of infertile women can be more safe, accurate, and affordable.

Office hysteroscopy is well established; its role for women with fertility concerns was explored. Areas discussed included the office/outpatient venue, the hysteroscopy team, patient preparation, hysteroscopy technique, analgesia and anaesthesia, and hysteroscopic morcellation procedures in the office setting.

The importance of a separate waiting area from the recovery room was stressed. A hysteroscopy room was viewed containing an examination couch and hysteroscopy stack; the need for a private changing area with washing facilities was noted.

A team consisting of hysteroscopist and two or three nursing staff providing patient care, both during and after the procedure, is important. Patients who attend for office hysteroscopy are anxious; good patient preparation with prior written information helps reduce concerns. Nurse support of the patient, the ‘local vocal’, was stressed.

Techniques for minimising pain were presented with gentle hysteroscopy, use of small diagnostic hysteroscopes (≤4mm diameter), maintaining a low intrauterine pressure, vaginoscopic entry into the uterine cavity taking care to follow the cervical canal, and how this is achieved with a 30° hysteroscope.

The evidence for which analgesics and types of local anaesthesia to use was reviewed, with reference to recent publications.

The range of hysteroscopic tissue removal systems (morcellators) for use in the office setting was viewed, with discussion about their differences. Most sizes of endometrial polyps, and the smaller submucosal fibroids (≤2 cm), are suitable for removal in this context. In view of the relatively large diameter of these operative scopes (5–7.25 mm) the need for use of cervical local anaesthetic was discussed, and the length of time required for this to become effective. As with the diagnostic procedures, these procedures are generally well tolerated by patients. Women awaiting fertility treatment particularly appreciate attending a ‘See and Treat’ appointment where intrauterine pathology can be removed during a single visit.

The role of medical management of intrauterine adhesions (IUA) is rather limited. Up to now, surgical treatment has been the only effective means to removing the adhesions. Traditional hysteroscopic adhesiolysis techniques include the use of hot wire (diathermy) or cold steel (scissors), usually requiring a general anaesthesia. Innovative office hysteroscopic techniques embraces the no-touch approach, balloon distension method, invisible knife and occasionally the use of topical anaesthesia with advantages over traditional pain management strategies such as paracervical block or non-steroidal analgesia or IV sedation. With the combined use of these innovative techniques, a significant proportion of cases of IUA may now be treated in the office setting with several important advantages, namely, cost-saving, reduction of risk, improvement of patient satisfaction, and increased acceptance of second look hysteroscopy to manage recurrence of IUA following surgery, which is a common occurrence and remains a great challenge to hysteroscopic surgeons.

Hysteroscopy has become an important tool to evaluate intrauterine pathology. Office hysteroscopy allows an efficient and accurate diagnosis of intrauterine pathology, including submucosal fibroids, endometrial polyps, cesarean scar defect, potential hyperplasia and cancer.

During the last decades, the introduction of small continuous-flow diameter scopes equipped with 5 Fr working channels has encouraged physicians to increase the number of operative procedures performed in an office setting. Vaginoscopic approach has greatly increased the feasibility and acceptability of office diagnostic and operative hysteroscopy minimizing patient’s pain and discomfort.

Therefore, knowledge of technologies, increased operator experience and selection of appropriate patients have played a key role in developing hysteroscopic surgery in an office setting.

Today, in most cases, the pathology can be diagnosed and concurrently treated. This ‘see-and-treat’ philosophy is the essence of one-stop clinics with resultant savings in time, cost and increased patient satisfaction.

Since many hysteroscopic procedures (removal of polyp and submucosal myomas, lysis of adhesions, retrieval of intrauterine device, removal of retained products of conception) can be performed in an office setting, a range of scopes (diagnostic and operative) is required in the surgical armamentarium of an ambulatory set-up. This can vary from traditionally available diagnostic (3-mm rigid and flexible) and rigid operative (5-4 mm) hysteroscopes to more complex state-of-the-art modern equipment, including mechanical instrument, bipolar or monopolar electrode and laser fiber.

The most recent development in operative hysteroscopy is the advent of a smaller diameter resectoscope 15-16 Fr and tissue removal system (HTRs). Polyps and myomas can be treated with these miniaturized instrumentations in an office setting with vaginoscopic approach without any cervical dilatation that is required with scope diameter greater than 5 mm.

In conclusion, the selection of hysteroscopic equipment for office surgery must be tailored to the patient acceptability and skill of the surgeon, this implies that the operator is trained and confident with the hysteroscopic system used to avoid additional cost for failed procedures and patient discomfort.

Debate: Hysteroscopy is mandatory before IVF

Position: AGAINST

The debate whether or not to recommend hysteroscopy for ALL patients who are to undergo their first IVF has been around for over two decades and can only be answered one way, and that is to rely on available reliable scientific evidence that gives irrefutable answers.

Going through the available current literature, there is still a dearth of evidence in randomized controlled trials without bias that can be put into a meta-analysis. The consistent findings of meta-analyses of RCTs is that there is low quality evidence due to heterogeneity and bias and that it cannot be used to support routine hysteroscopy for subfertile women who are about to undergo IVF.

In the absence of robust data, it is recommended that clinicians focus on improving means to detect uterine lesions in patients about to undergo their first IVF. This includes improvements in ultrasound detection and identification of risk factors for the presence of some of these uterine pathologies.

Position: FOR

Advancement in modern day hysteroscopic procedures has proved to be the game changer in achieving better results in artificial reproductive techniques. But answer to this riddle remains unsolved that whether to go ahead with hysteroscopy in all IVF cycles irrespective of normal uterine anatomy ascertained by other less reliable methods like ultrasound, saline infusion sonography or hysterosalpingography or not.

There are number of arguments favouring hysteroscopy in all cases.

Firstly, minor uterine anomalies like polyps, septum (partial or complete), myomas and adhesions play important role in decreasing the chances of IVF success. Moreover, all these causes may not be efficiently diagnosed by other diagnostic procedures. Data suggest that prevalence of unsuspected intrauterine abnormalities, diagnosed by hysteroscopy prior to IVF has been reported to be 11-45%.

Secondly, accuracy of TVS, SIS and HSG has been questioned at times in diagnosing these anomalies. SIS has been useful in diagnosing abnormalities like polyps and adhesions to greater extent. Considering its cost and convenience of performing, it has increasingly been popular for diagnosis. However, major drawback with all these procedures is that we cannot see and treat at the same time as we do while performing hysteroscopy.

Thirdly, considering the overall cost of IVF cycle and the emotional & financial burden carried by the couple, we cannot afford the failure of a cycle because of treatable intrauterine pathology (by hysteroscopy) inadvertently missed by other diagnostic tools.

Fourthly, various studies and evidence have shown that pretransfer hysteroscopy has proven to be resulting in better live birth rates and clinical pregnancy rates.

Fifthly, the other benefits of a hysteroscopy include direct observation of vaginal wall, external os, cervical canal, endometrial cavity and allows the surgeon to perform minor procedures such as treatment of erosions, removing small polyps, scratching the endometrium, and taking samples for receptivity analysis in cases of recurrent implantation failure. They greatly enhance the overall success rate of an IVF cycle. It also enables the surgeon to anticipate any difficulties to be encountered during the transfer.

To conclude, it can be suggested that considering the cost, suboptimal diagnosing capabilities of other tools and enabling see and treat the pathology, hysteroscopy should be performed before transfer in all IVF cycles to optimise the results.