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HYSTEROSCOPY FOR INFERTILE PATIENT An Evidence Based
ApproachDr.Mohamed El SherbinyMD Obstetrics&Gynecology Senior
Consultant Damietta General HospitalDamietta Egypt
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DIAGNOSTIC HYSTEROSCOPY
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SHOULD HYSTERSCOPYBE DONE ROUTINLY INTHE EVALUATION OF
INFERTILITY ?NO
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Indications of Diagnostic Hysteroscopy for Reproductive
FailureAbnormal hysterosalpingogram.Abnormal uterine bleeding
Suspected intrauterine pathologyUterine anomaliesPregnancy
wastageUnexplained infertilityValle 1996
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SHOULD HYSTEROSCOPY BE USED ROUTINELY AT THE TIME OF LAPAROSCOPY
FOR . THE INVESTIGATION OF . INFERTILIY ?
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El Sherbiny M, Medical J of Cairo Univ., Vol.65 No. 3, Sept.
1997El Sherbiny M, The 7th Annual Meeting Of The Intern. Society
for Gynecologic Endoscopy ,Sun City, South Africa;15:18 March,1998
Hysteroscopy done at laparoscopy time, has low complication rate,
high degree of safety, minimal time requirement and adds little
equipment & cost. Positive hysteroscopic findings were found in
many cases (15%) despite having normal HSG and no suggestive
history of uterine lesion
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Unexplained infertilitySmall endometrial polypSmall cervical
polypAdhesion at cornual conesCornual polypEndometrial
dystrophies(atrophy or hyperplasia) that may affect receptivity or
implantation especially in ART.
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`Unexplained infertilityCornual polypcervical polypHSG is
free
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OPERATIVE HYSTEROSCOPY
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Indications of Operative Hysteroscopy for Reproductive
FailurePolyp.Submucous leiomyoma.Uterine septa.Intrauterine
Adhesions.Misplaced or embedded IUDTubal cannulation &
Falloposcopy. Valle 1996
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3638Uterine PolypSonohysterographyHysteroscopy
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Intrauterine synechiae
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HSG: Filling defectStellate & irregular,Commonly
inhomogeneousHYSTEROSCOPYConfirmationEvaluation of the extent of
the diseaseIntrauterine Synechiae
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The American Fertility Society classification of intrauterine
adhesions.1988. Extent of < 1/3 1/3 - 2/3 >2/3 Cavity
Involved 1 2 4 Type of Filmy filmy & Dense Dense Adhesions 1 2
4 Menstrual Normal Hypomenorrhea Amenorrhea Pattern 0 2 4 Stage I
(Mild) 1 - 4 Stage II (Moderate 5 - 8 Stage III (Severe) 9 - 12
Combined HSG& hysteroscopy & clinical
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Intrauterine SynechiaeSevereModerate
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Septate Uterus : Value of HysteroscopyConfirming the abnormality
Evaluating the uterine cavity capacity Discarding other pathologic
findings such as polyps, endometritis, hypertrophy Guiding surgical
aproachTraver et al. Infertility in the 3rd Millennium Prague,
2000
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Resection of the Uterine Septum121Laparoscopic
GuidedSeptumCollin's Electrode
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Proximal Tubal Obstruction(PTO)
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Proximal Tubal ObstructionFibrosis obliteration&SIN
40%Endometriosis &Cornual polyp 10%Cornual spasm 20%Amorphous
material 50%Viscous secretions 30% Mucosal agglutination Stromal
edemaValle 1996
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Oil-soluble Versus Water-soluble Media for
Hysterosalpingography
Flushing of the tubes with oil-soluble media increases
subsequent pregnancy rates in infertility patients. It may flush
tubal "plugs" that are a cause of proximal tubal occlusion
.Clinicians should consider flushing the tubes with OSCM before
contemplating more invasive therapies.Vandekerckhove et al., July
1996 (Cochrane Review). In: The Cochrane Library, Issue 2 2002.
Oxford: Update Software.
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Tubal Catheterization Where proximal tubal obstruction is
suspected, and there are no other tubal abnormalities, a tubal
catheterisation procedure may be attempted RCOG Guidelines : Grade
B Recommendation
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Tubal CatheterizationBilateral Cornual BlockAmorphous materialR.
OvaryR. fimbriaCornual catheterization
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Thank You
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