30/10/2015
Hysteroscopy can save you from IVF – A Necessary & Important Gold Standard Fertility Enhancing Procedure
Medical Author
Dr. Piyush S. Goyal MD
Consultant Obstetrician & Gynaecologist.
Laparoscopic Surgeon & Infertility Specialist, Urogynaecologist
Mobile - +919820045689 Email – [email protected]
Agarwal Nursing Home
74, Anne Villa, Junction of 14th & 30th Road, Near Saint Theresa High School.
Bandra West, Mumbai – 400050, Call - 02226455124, 02226455125
Date – 30th October 2015
INTRODUCTION
Hysteroscopy is a valuable diagnostic and therapeutic modality in the management of infertility which can save a patient from an IVF cycle.
Hysteroscopy is performed approximately half the time for the diagnosis of infertility. It is generally best performed in the postmenstrual proliferative phase.
Various aspects at different levels need a thorough evaluation to better success rates for patients.
1. Uterocervical Length with the help of a uterine sound.
2. Mapping the Direction of the Vagino-Cervico Uterine Axis after assessing the position of the uterus.
3. Vaginoscopy – Visualization with evaluation of the va**na, to detect the va**nal environment, infection, presence of any growth or lesion.
4. Cervicoscopy – The cervix also need to be studied in detail.
• Evaluation of the External Os – To detect any infection on the external os, cervicitis, erosion or growth
• Evaluation of the Cervical Canal – Presence of any Endocervical pathology like endocervical polyps, myomas or cysts which obliterate the canal and create obstruction for an easy access to the uterine cavity at the time of embryo transfer.
• Evaluation of the Internal Os – To detect Stenosis at the level of the internal os, which could be because of fibrosis or the presence of a growth like a polyp or myoma.
In my experience I have noted that identifying and correcting the cervical factors can increase the success rate tremendously.
5. Hysteroscopy Visualization and Evaluation of the uterine cavity.
• Isthmus – Lower one third of the uterine cavity just above the internal os
• Uterine Cavity - Evaluation of the cavity is of great importance
• Size – A small uterine cavity needs to be identified and treated with a metroplasty.
• Shape & Contour – A cylindrical uterine cavity can be corrected with a Lateral Metroplasty.
• Fundus – Presence of a septum and alteration in the fundal anatomy warrants a septal resection. Correction of Arcuate and Septate uteri is important to increase the success rates in fertility treatment.
• Ostia – Fibrosis of Block of the Ostia can be tackled by cornual cannulation and the fallopian tubes can be opened up.
• Endometrium – Evaluation of the vascularity and appearance of the endometrium is very important. Sub Mucous Polyps and Myomas need to be hysteroscopically resected and a normal uterine cavity has to be restored.
6. A gentle curettage / scratching of the endometrium should be performed and sent for Histopathological examination to detect the presence of infection. In addition endometrium should also be subjected to a TB PCR Investigation and if detected then should be treated for better results.
One recent review of endometrial scratching described endometrial receptivity as one of the key factors regulating embryo implantation and proposed "that mechanical trauma to the endometrium alters gene expression, enhances secretion of growth factors and makes it more receptive for implantation." Results of the review suggested that endometrial scratching is 70% more likely to result in pregnancy than no treatment. A more recent review -- but examining the same studies -- concluded that "hysteroscopy and/or endometrial scratching in the cycle preceding ovarian stimulation should become a standard for patients with [recurrent implantation failure].
7. Serial Cervical Dilatation with Hegar dilators will ensure that the cervical stenosis is cleared to ease further treatments.
A large multicentric trial finally has resolved one of IVF's long-running controversies - whether the outlook for women with a poor IVF record can be improved by routine hysteroscopy performed before further IVF treatment.
For the TROPHY study, whose results are reported has now found no significant difference in IVF success rates between those who had outpatient hysteroscopy performed before their IVF and those who didn't. "Based on these findings, outpatient hysteroscopy before IVF doesn't significantly improve IVF results and cannot be considered essential for women with recurrent IVF failure," Only around one-third of IVF cycles achieve a pregnancy, and unsuccessful attempts (implantation failure) can usually be explained by embryonic or uterine factors.
As a result, outpatient hysteroscopy is performed routinely in many fertility clinics before further attempts, first diagnostically to visualise the surface of the uterus and check for any abnormal growths, and then operatively during the same procedure to remove these growths. This has proved to improve success rates.
CONCLUSIONS
In order for a fertility treatment cycle to succeed, the embryos need a healthy uterus in which they can implant. There are many tests to evaluate the uterine cavity and the endometrial lining. These include non-invasive tests such as ultrasound scans and a HSG, and invasive tests such as hysteroscopy. The most accurate method for evaluating the uterine cavity is a hysteroscopy, because it allows the doctor to actually look inside the uterus.
Routinely performing a hysteroscopy for every patient prior to doing an IVF cycle is considered to be a part of basic pre-IVF evaluation, along with the semen analysis and the testing for ovarian function.
Routinely performing a hysteroscopy allows experts to pick up & correct intra uterine pathologies which would otherwise be missed by other techniques such as ultrasound scanning, because these non-invasive tests are not as reliable or sensitive as a hysteroscopy.
Consultants feel that if a patient is going to spend money on an IVF cycle, then it makes sense to evaluate and optimize the cycle so it will improve the success rate of having a baby.
Dr. Piyush Goyal MD
