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OFFICE HYSTEROSCOPY IN INFERTILITYOFFICE HYSTEROSCOPY IN INFERTILITY Muammer DOGAN, MD. Muammer DOGAN, MD.

HysteroscopyHysteroscopyInstrumentationInstrumentation

Lockable cabinetLockable cabinetTelescopeTelescopeSheath systemSheath system

HysteroscopeHysteroscope

DiagnosticDiagnostic

OperativeOperativeResectoscopeResectoscope

Distention systemsDistention systemsGas insufflatorGas insufflatorFluid delivery Fluid delivery systemsystem

Light source and cableLight source and cable Video cameras and monitorsVideo cameras and monitors

Sterilization ofSterilization of InstrumentsInstruments

It is not necessary for operators to It is not necessary for operators to wear scrub suits, gowns, masks, or wear scrub suits, gowns, masks, or caps to perform office caps to perform office hysteroscopy. hysteroscopy. Sterile gloves are mandatory, and Sterile gloves are mandatory, and any instruments inserted into the any instruments inserted into the uterus must be sterile.uterus must be sterile.

Sterilization ofSterilization of InstrumentsInstruments

Accessory instruments can be Accessory instruments can be autoclaved or soaked in appropriate autoclaved or soaked in appropriate sterilized solutions. sterilized solutions. Telescopes should never be Telescopes should never be autoclaved but should be sterilizing autoclaved but should be sterilizing in the appropriate solutions. in the appropriate solutions.

Hysteroscopes / SheathsHysteroscopes / Sheaths

Flexible (3-5 mm)Flexible (3-5 mm)Adv.Adv. Minimal risk of trauma, ability to deflect Minimal risk of trauma, ability to deflect the view manuallythe view manuallyDisadv.Disadv. Greater cost, inability to widen view or Greater cost, inability to widen view or to magnify the image, inability to use the to magnify the image, inability to use the instrumentinstrument

Rigid (4 mm) 0-30 degrees Rigid (4 mm) 0-30 degrees Microhysteroscope (2.4-2.7 mm)Microhysteroscope (2.4-2.7 mm)

Light SourceLight Source

The optics of telescope 150 – W The optics of telescope 150 – W light source with flexible fiber optic light source with flexible fiber optic cablescablesHalogen or xenon types bulbs for Halogen or xenon types bulbs for video cameras and monitorsvideo cameras and monitors

Distention mediaDistention media

CO2CO2 Low flow, low flow insufflatorsLow flow, low flow insufflatorsflow rates 100mL /m, press. 125mmHg, flow rates 100mL /m, press. 125mmHg, Adv.Adv. Low cost, visibility good if no Low cost, visibility good if no bleeding, bleeding, Disadv.Disadv. Requires hys.insufflator, Requires hys.insufflator,Shoulder pain, uterine cramping, Shoulder pain, uterine cramping, Absorbed by blood and released thru Absorbed by blood and released thru pulmonary ventilation pulmonary ventilation


Dextran 70 or Hyskon Dextran 70 or Hyskon ( High-viscosity fluid)( High-viscosity fluid)

Adv.Adv. Visibility excellent even with Visibility excellent even with bleeding, bleeding, Disadv.Disadv. ExpensiveExpensive, caramelize when , caramelize when it dries, it dries, allergic reactionsallergic reactions (anaphylactic shock), very thick and (anaphylactic shock), very thick and messy, do not use with continuous messy, do not use with continuous flowflow


Normal saline , Ringer’s lactateNormal saline , Ringer’s lactate( Low-viscosity fluid)( Low-viscosity fluid)

Best with continuous flow, clear view, Best with continuous flow, clear view, costly insufflators and pumps are costly insufflators and pumps are unnecessary, bipolar proceduresunnecessary, bipolar proceduresSorbitol, Glycine, MannitolSorbitol, Glycine, Mannitol ( Low-viscosity fluid)( Low-viscosity fluid)Monopolar proceduresMonopolar procedures

DistenDistenttion Media:Saline Vs ion Media:Saline Vs CO2CO2

Normal saline should be used as it Normal saline should be used as it offer: advantages (shorter and less offer: advantages (shorter and less discomfort ) over CO2 instillation.discomfort ) over CO2 instillation.

New Zealand Guidelines GroupNew Zealand Guidelines Group

CO2 Fluid medium

Technical expenditure Higher Low

Risk of dissemination Very low Slightly higher

Picture Very clear Clear

Diagnosis of bleeding Limited Very good disorders

Comparison of fluid and CO 2 distention media

TIMINGTIMING

It is preferable to perform It is preferable to perform hysteroscopy in the hysteroscopy in the proliferative phase or proliferative phase or immediately following a immediately following a menstrual period.menstrual period.

Hysteroscopy - BenefitsHysteroscopy - Benefits

Direct visualization of any Direct visualization of any pathologypathology

No X-ray exposureNo X-ray exposureInsertion under visualization Insertion under visualization decreases chance of perforationdecreases chance of perforation

Indication of Office Indication of Office hysteroscopy for reproductive hysteroscopy for reproductive failurefailure

Abnormal HSGAbnormal HSGUterine abnormalitiesUterine abnormalities (septae)(septae)Unexplained uterine Unexplained uterine bleedingbleedingSuspected intra- Suspected intrauterine pathologyuterine pathology (polyps, myomas, (polyps, myomas, adhesions, foreign bodies)adhesions, foreign bodies)Pregnancy wastagePregnancy wastageUnexplained Unexplained infertility ?infertility ?

Valle 1996.Valle 1996.

Controversial IndicationControversial Indication

All infertile patientsAll infertile patientsBefore IVFBefore IVFPerimenopausal screeningPerimenopausal screeningEmbryo replacementEmbryo replacementDelivery of laser therapyDelivery of laser therapy

HysteroscopyHysteroscopyContraindicationsContraindications

Active PIDActive PIDActive profuse uterine bleedingActive profuse uterine bleedingRecent uterine perforationRecent uterine perforationPregnancyPregnancyCx Ca Cx Ca Cardiovascular or systemic Cardiovascular or systemic diseasesdiseases

HysteroscopyHysteroscopyComplicationsComplications

Uterine perforationUterine perforationHemorrhageHemorrhageInfectionInfectionHypervolemiaHypervolemiaHyponatremic encephalopathy and cardiac Hyponatremic encephalopathy and cardiac asystole, arrhythmiaasystole, arrhythmiaHypercarbia, acidosis, gas embolismHypercarbia, acidosis, gas embolism

OFFICE HYSTEROSCOPYOFFICE HYSTEROSCOPY

Because of excellent drainage, the Because of excellent drainage, the risk for infection with risk for infection with office office hysteroscopy is exceedingly low. hysteroscopy is exceedingly low.

( 0.1%-2.8%)( 0.1%-2.8%)


The outpatient hysteroscopy The outpatient hysteroscopy failure rate is less than half (2%) failure rate is less than half (2%) with the mini-hysteroscope with the mini-hysteroscope compared with the traditional 5 compared with the traditional 5 mm hysteroscope (5%).mm hysteroscope (5%).De Angelis C Hum Reprod. 2003;18:2441-5De Angelis C Hum Reprod. 2003;18:2441-5..


Office flexible minihysteroscopes Office flexible minihysteroscopes (2.5 and 3.5 mm) can be (2.5 and 3.5 mm) can be successfully used in an office successfully used in an office setting for gynecologic indications setting for gynecologic indications with high patient acceptance.with high patient acceptance. Ross JW. J Am Assoc Gynecol Laparosc. 2000 Ross JW. J Am Assoc Gynecol Laparosc. 2000

;7:221-6.;7:221-6.


Risk of vasovagal syndrome is higher Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope with the use of a rigid hysteroscope and CO2, regardless of the and CO2, regardless of the indication for hysteroscopy or the indication for hysteroscopy or the parity and menopausal status of the parity and menopausal status of the patient.patient.Agostini A, J Am Assoc Gynecol Laparosc. 2004 Agostini A, J Am Assoc Gynecol Laparosc. 2004

;11(2):245-7;11(2):245-7


Saline office diagnostic Saline office diagnostic hysteroscopy offers at least all the hysteroscopy offers at least all the advantages of the CO2 advantages of the CO2 hysteroscopy, and gives the hysteroscopy, and gives the possibility to easily 'find and treat possibility to easily 'find and treat in situ' many of the lesions in situ' many of the lesions observed.observed.Perez-Medina T Int J Gynaecol Obstet. 2000 Perez-Medina T Int J Gynaecol Obstet. 2000

;71:33-8.;71:33-8.


The best advice is to have a set of The best advice is to have a set of instruments that can be modifiable instruments that can be modifiable for each specific situation, that is, for each specific situation, that is, small diagnostic hysteroscopes and small diagnostic hysteroscopes and sheaths for pure diagnostic sheaths for pure diagnostic evaluation that then can be changed evaluation that then can be changed with a larger diagnostic sheath with a larger diagnostic sheath containing an operating channel to containing an operating channel to accommodate biopsy or grasping accommodate biopsy or grasping forceps when needed.forceps when needed.

Preparation of the cervixPreparation of the cervix

Vaginal misoprostol prior to Vaginal misoprostol prior to diagnostic hysteroscopy diagnostic hysteroscopy reduced reduced cervical resistance in cervical resistance in nonpregnant nonpregnant womenwomen..

Fong&Sing. Evidence-based Fong&Sing. Evidence-based Obs&Gyn 2001;3:88Obs&Gyn 2001;3:88

Dilatation, laminaria tents ??Dilatation, laminaria tents ??

ANALGESIA ANALGESIA ANESTHESIAANESTHESIA

Pain, cramping, vagal reaction Pain, cramping, vagal reaction 10% 10%

Para cervical blockPara cervical block

In severe problemIn severe problem;;Atropine 0.1-0.2 mg IM Atropine 0.1-0.2 mg IM

with/withoutwith/withoutKetorolac 30 mg IMKetorolac 30 mg IMIV sedation (rarely)IV sedation (rarely)

TECHNIQUETECHNIQUE

CO2CO2 ⇉⇉ the telescope should be the telescope should be the first instrument through the first instrument through the canalthe canalInspection Inspection FundusFundus ⇉⇉ lower uterine segment lower uterine segment

⇉⇉ cervical canal cervical canal

TECHNIQUETECHNIQUE

Analgesia-anesthesia-vaginal region cleaning, Analgesia-anesthesia-vaginal region cleaning, No speculum- no tenaculum No speculum- no tenaculum (Vaginoscopical approach)(Vaginoscopical approach)Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3: Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3:

Supplement-S4.Supplement-S4. Fluid distention media, continuous flowFluid distention media, continuous flowEndomat; irrigation pressure=75-100 mm Hg, Endomat; irrigation pressure=75-100 mm Hg, Flow=200-350 ml/min; suction= (-) 0.25 barFlow=200-350 ml/min; suction= (-) 0.25 bar2.9 mm scopy (302.9 mm scopy (30oo))Operating canal (1.6 mm) Operating canal (1.6 mm)

(Operative office hysteroscopy)(Operative office hysteroscopy)

ectocervix endocervical canal

internal os


Intrauterine endometrial polyp

Sub mucous myoma without intramural extension (type 0, ESGE classification).

Sub mucous myoma with typical stretched and dilated capsular vessels.


Hysteroscopy done at laparoscopy time, Hysteroscopy done at laparoscopy time, has low complication rate, high has low complication rate, high requirement and adds little equipment & requirement and adds little equipment & cost. Positive hysteroscopic findings were cost. Positive hysteroscopic findings were found in many cases (15 %) despite having found in many cases (15 %) despite having normal HSG and no suggestive history of normal HSG and no suggestive history of uterine lesion.uterine lesion.

El Sherbinym 1998.El Sherbinym 1998.


Operative office hysteroscopy without Operative office hysteroscopy without anesthesia: analysis of 4863 cases anesthesia: analysis of 4863 cases performed with mechanical instruments performed with mechanical instruments Simple instruments enable us to perform Simple instruments enable us to perform many operative procedures in an office many operative procedures in an office setting with excellent patient setting with excellent patient satisfaction, provided that the indications satisfaction, provided that the indications are correct.are correct.Bettocchi S, J Am Assoc Gynecol Laparosc. 2004 Bettocchi S, J Am Assoc Gynecol Laparosc. 2004

;11:59-61.;11:59-61.

Reference n %

Lindemann-Mohr (1976) 1100 29 Siegler (1977) 77 39 Taylor-Cumming (1977) 68 44 Valle (1989) 142 62 Snowden et al (1984) 61 1.3 Keisler-Lancet (1986) 16 31.8 Fayez et al (1987) 194 24 Seinera et al (1988) 332 44.5 Dicker et al (1990) 284 30 Goldenberg (1991) 224 19 Kirsop et al (1991) 10 10 Golan et al (1992) 40 10

Normal HSG Vs abnormal hysteroscopy

Abnormal HSG Vs normal hysteroscopy

Reference n % Goldberg et al-1997 40 20

Snowden et al-1984 61 10Fayez et al-1987 85 30Valle-1983 122 31-57Keltz et al-1997 34 31Golan et al-1996 464 55Wang et al-1995 214 13


Hysteroscopy should not be Hysteroscopy should not be considered as a routine considered as a routine investigation investigation in the infertile in the infertile couple.couple.

RCOG Guidelines: 1999 Grade C RCOG Guidelines: 1999 Grade C recommendationrecommendation..

When hysteroscopy should be When hysteroscopy should be done for unexplained done for unexplained infertility?infertility?

At laparoscopy ?At laparoscopy ?Before IVF ?Before IVF ?After failed IVF ?After failed IVF ?

Unexplained InfertilityUnexplained Infertility

Small endometrial polypSmall endometrial polypSmall cervical polypSmall cervical polypAdhesion at cornual conesAdhesion at cornual conesCornual polypCornual polyp

Endometrial atrophy or Endometrial atrophy or hyperplasia that may hyperplasia that may affect receptivity or affect receptivity or

implantation especially in ART implantation especially in ART


In an IVF-ET program patients with In an IVF-ET program patients with normal hysterography but abnormal normal hysterography but abnormal hysteroscopic findings had a hysteroscopic findings had a significantly lower clinical PR, significantly lower clinical PR, demonstrating the importance of demonstrating the importance of performing hysteroscopy before performing hysteroscopy before IVF-ET.IVF-ET.Shamma FN, Fertil Steril. 1992 Dec;58(6):1237.Shamma FN, Fertil Steril. 1992 Dec;58(6):1237.


DDiagnostic hysteroscopy should iagnostic hysteroscopy should be performed on all patients be performed on all patients before they undergo IVF-ET.before they undergo IVF-ET. La Sala GBFertil Steril. 1998 ;70:378-80.La Sala GBFertil Steril. 1998 ;70:378-80.


When hysteroscopy is routinely When hysteroscopy is routinely performed performed prior to in vitro fertilizationprior to in vitro fertilization, a , a significant percentage of patients have significant percentage of patients have uterine pathology that may impair the uterine pathology that may impair the success of fertility treatment. Patient success of fertility treatment. Patient tolerance, safety, and the feasibility of tolerance, safety, and the feasibility of simultaneous operative correction make simultaneous operative correction make office hysteroscopy an ideal procedure.office hysteroscopy an ideal procedure.

Hinckley MD, JSLS. 2004 ;8:103-7. Hinckley MD, JSLS. 2004 ;8:103-7.


Patients with normal hysterosalpingo-Patients with normal hysterosalpingo-graphy but recurrent IVF-embryo graphy but recurrent IVF-embryo transfer failure should be evaluated prior transfer failure should be evaluated prior to commencing IVF-embryo transfer cycle to commencing IVF-embryo transfer cycle to improve the clinical pregnancy rate.to improve the clinical pregnancy rate.Demirol A, Gurgan T. Reprod Biomed Online. Demirol A, Gurgan T. Reprod Biomed Online.

2004 ;8:590-42004 ;8:590-4..


Systematic hysteroscopy prior to Systematic hysteroscopy prior to IVF-ICSI showed to be an effective IVF-ICSI showed to be an effective investigation that could improve the investigation that could improve the pregnancy rate.pregnancy rate.

Feghali J, Gynecol Obstet Fertil. 2003 ;31:127-Feghali J, Gynecol Obstet Fertil. 2003 ;31:127- 31. 31.


The role of office hysteroscopy in The role of office hysteroscopy in menopause. Many operative menopause. Many operative procedures may be performed in procedures may be performed in the office setting with simple the office setting with simple instruments, provided that instruments, provided that correct indications are observed.correct indications are observed.Bettocchi S, J Am Assoc Gynecol Laparosc. Bettocchi S, J Am Assoc Gynecol Laparosc.

2004 ;11:103-6.2004 ;11:103-6.


Office hysteroscopy has become an Office hysteroscopy has become an important tool in the armamentarium important tool in the armamentarium of the gynecologist, especially in the of the gynecologist, especially in the evaluation of AUB, evaluation of AUB, infertilityinfertility, and , and pregnancy wastagepregnancy wastage


It is no more acceptable for a It is no more acceptable for a gynecologist to insert a sharp gynecologist to insert a sharp curette into a uterine cavity blindly curette into a uterine cavity blindly to discover and remove suspected to discover and remove suspected pathology than it is for an pathology than it is for an orthopedist to insert a curette into orthopedist to insert a curette into a knee joint blindly.a knee joint blindly.

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