Role of Hysteroscopy in
Infertility
Dr Rajesh Gajbhiye
Consultant Gynecologist and
Laparoscopic Surgeon.
Director Mauli Women’s Hospital,
Nagpur
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Fertility ..
Good ovum, Good Sperm
Good embryo
Patent and functioning tube
Good Uterine cavity
Receptive Endometrium
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Hysteroscopic Surgeon
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Content
Diagnostic Hysteroscopy
Submucous Fibroid
Uterine septum
Intrauterine Adhesions
Endometrial Polyp
Proximal Tubal Block
Prior to ART
Endometrial Scratching
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Introduction
Uterine factors can be found in only 2 to 3%
of infertile women, but intrauterine lesions are
much more common in this setting (40–50%)
These lesions can compromise spontaneous
fertility as well as reduce pregnancy rates in
assisted reproduction .
Published observational studies suggest
increased pregnancy rates after the
hysteroscopic removal of endometrial polyps,
submucous fibroids, uterine septum, or
intrauterine adhesions, which can be found in
10% to 15% of women seeking treatment for
subfertility.
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Diagnostic Hysteroscopy
Evaluation of the uterine cavity is a
basic step in female infertility workup.
Transvaginal sonography
Hysterosalpingography and are most
commonly used for this purpose.
Hysteroscopy, however, is considered
the gold standard for diagnosis of
intrauterine lesions.
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American Society for
Reproductive Medicine (ASRM)
Hysteroscopy is the definitive method
for the diagnosis and treatment of
intrauterine pathology.
Costly and invasive method for uterine
cavity evaluation, it should be
reserved for further evaluation and
treatment of abnormalities defined by
less invasive methods such as HSG
and sonohysterography [Fertility and
Sterility, vol. 98, no. 2, pp. 302–307, 2012 ]
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Diagnostic Hysteroscopy
Normal 2D/3D USG/ HSG
Unexplained infertility
Uterine anomaly
Prior to IVF
Repeated IVF Failures
Suspected endometrial pathology
Recurrent abortion
Abnormal uterine bleeding
In combination with laparoscopy and TVS
Gives complete diagnosis
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Submucous fibroid
According to the ASRM (2008) -
intracavitary myomas and submucous
myomas having at least 50% of their
volume within the uterine cavity.
In infertile women and those with
recurrent pregnancy loss,
myomectomy should be considered
only after a thorough evaluation has
been completed.
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Type0 & 1
hysteroscopic
myomectomy
Types of submucous fibroids
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Meta-analysis-Submucous
fibroid
Pritts et al. 2009 - studies regarding
the effect of fibroids on fertility and of
myomectomy in improving outcomes.
They concluded that fertility outcomes
are decreased in women with
submucosal fibroids
Removal seems to confer benefit in
terms of pregnancy rates.
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RCT-Submucous fibroid..
T. Shokeir, et al Fertility and Sterility, vol. 94, no. 2, pp.
724–729, 2010
Prospective randomized matched
control trial, 215 women with
unexplained primary infertility and with
ultrasonographically diagnosed
submucous fibroids were enrolled.
Women in the study group had a better
possibility of becoming pregnant after
hysteroscopic myomectomy.
No difference in pregnancy rates was
observed according to fibroid size,
number, and location in both groups.
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Uterine Septum
Septal resection improves outcome in
BOH
Its role in Infertility ?
Current data does not give its causal
role
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Metroplasty
Most studies of metroplasty for a septate
uterus combine women with recurrent
miscarriage and infertility, and no study
has been published that randomizes
infertile women to treatment versus no
treatment. For this reason controversy
exists as to whether infertile women
should undergo metroplasty
C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty
versus expectant management for women with recurrent
miscarriage and a septate uterus,” Cochrane Database of
Systematic Reviews, no. 6, Article ID
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Uterine Septum
Some recommended surgery and
some not but randomized data is
lacking.
Pabuccu et al found 41% spontaneous
pregnancy rates after septal resection
in patients with unexplained infertility
with septum.
Long standing infertility with septum
and otherwise unexplained.
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Hysteroscopic septal
resection
Microscissors,
electrorosurgery,
fiberoptic laser
energy.
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Metroplasty.
Reproductive outcomes are improved
after hysteroscopic resection.
Fedele et al evaluated the
reproductive outcome after
hysteroscopic metroplasty in 31
women with infertility and 71 women
with miscarriage, and reported a
cumulative pregnancy rate of 89% at
36 months for patients with complete
septum and 80% for those with partial
septum
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Reproductive Outcome following Hysteroscopic
Monopolar Metroplasty: An Analysis of 203
Cases
Ensieh Shahrokh Tehraninejad
Int J Fertil Steril. 2013 Oct-Dec; 7(3): 175–180.
Evaluate the reproductive outcome of
women with history of infertility or
recurrent miscarriage following
hysteroscopic septum resection
Term deliveries increased significantly
from 2.5 to 33.5%.
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Metroplasty
Laparoscopic guidance frequently is
used during hysteroscopic metroplasty
to reduce the risk of uterine
perforation.
IUD insertion for 3 months with
estrogenisation is only recommended
for complete or wide septa.
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Intrauterine Adhesions
Intrauterine trauma resulting from
vigorous endometrial curettage
After multiple myomectomy,septum
resection.
Associated with RPL.
The severity of adhesions may range
from minimal to complete
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ESGE Grade 3&4 require
electrosurgical adhesiolysis and
pregnancy rates are 20-40%
Post op IUD and estrogen is
adminsitered after electrosurgical
adhesiolysis.
Complication rates are also high
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T sahped uterus
Pts with TB
Narrow constricted,T
shaped cavity
Decreased
menstrual flow and
amenorrhoea
Metroplasty fundal
and lateral
Post op estrogen
and IUD
Better pregnancy
rates with IVF ET
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Cochrane review
Hysteroscopic myomectomy might
increase the odds of clinical pregnancy
in women with unexplained subfertility
and submucous fibroids, but the
evidence is at present not conclusive.
Hysteroscopic removal of endometrial
polyps suspected on ultrasound in
women prior to IUI might increase the
clinical pregnancy rate J. Bosteels,
“Hysteroscopy for treating subfertility associated with
suspected major uterine cavity
abnormalities,” Cochrane Database of Systematic
Reviews, no. 1, Article ID CD009461, 2013
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Hysteroscopic tubal cannulation
appears to be more effective than
fluorosocpic guided canulation or open
microsurgical repair or IVFET.
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Endometrial Polyps
Localized overgrowths of endometrium.
Polyps can distort the endometrial cavity,
may have a detrimental effect on
endometrial receptivity, and increase the
risk of implantation failure .
The gold standard for diagnosis is
hysteroscopy and hysteroscopic
polypectomy remains the mainstay of
management.
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Endometrial Polyp
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Endometrial polyps
A recent Cochrane review tried to assess the
effect of hysteroscopic polypectomy on the
results of intrauterine insemination (IUI).
Apparently, the hysteroscopic removal of polyps
prior to IUI increases the odds of clinical
pregnancy compared to diagnostic hysteroscopy
and polyp biopsy only (OR 4.4, 95% CI 2.5 to
8.0, and ).(J. Bosteels)
Implantation and clinical pregnancy rates were
statistically significantly increased after
hysteroscopic polypectomy in a group of women
with recurrent implantation failure after IVF. I.(
Stamatellos)
In conclusion, it appears that polypectomy prior
to IUI or IVF (even I cases with previous
implantation failure) increases the chances of
pregnancy. 17/08/2014 CGISAR 36

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For the infertile patient with a polyp,
surgical removal is
recommended to allow natural
conception or assisted reproductive
technology a greater opportunity to
be successful
(Level A).
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Hysteroscopy prior to ART
A systematic review comparing the
outcome of IVF treatment performed in
patients who had outpatient
hysteroscopy.
The results of five studies showed
evidence of benefit from outpatient
hysteroscopy in improving the
pregnancy rate in the subsequent IVF
cycle.
F. Lorusso, O. Ceci, S. Bettocchi et al., “Office
hysteroscopy in an in vitro fertilization
program,”Gynecological Endocrinology, vol. 24, no. 8,
pp. 465–469, 2008. 17/08/2014 CGISAR 39

Hysteroscopy prior to 1st IVF
A systematic review and meta-
analysis Jyotsna Pundir et al
Reproductive BioMedicine Online
Volume 28, Issue 2 , Pages 151-161, February
2014
Hysteroscopy in asymptomatic woman prior to their
first IVF cycle was found to be associated with
improved chance of achieving a pregnancy and live
birth when performed just before commencing the
IVF cycle.
Robust and high-quality randomized trials to
confirm this finding are needed to further guide
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Currently, there is evidence that
performing hysteroscopy before starting
IVF treatment could increase the chance
of pregnancy in the subsequent IVF
cycle in women who had one or more
failed IVF cycles (Bosteels et al,
2010 and El-Toukhy et al, 2008).
However, recommendations regarding
the efficacy of routine use of
hysteroscopy prior to starting the first IVF
treatment cycle are lacking.17/08/2014 CGISAR 41

Hysteroscopy prior to ART
Another recent study included 157 women
with a history of recurrent IVF failures (two or
more) who underwent hysteroscopy
(diagnostic or operative, as appropriate) to
evaluate the endometrial cavity. Abnormal
hysteroscopic findings were found in 44.9%
of the patients in this study and 75 women
(48.1%) became pregnant following
hysteroscopy. Of these pregnancies, 36
occurred in women with corrected
endometrial pathology, the majority of which
was polyp.
P. Cenksoy et al Archives of Gynecology and
Obstetrics, vol. 287, no. 2, pp. 357–360, 2013.
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Endometrial scratching improves IVF pregnancy rate
BMJ 2013; 347
Endometrial scratching involves
causing intentional damage to the
endometrium through biopsy or
curettage.
An association between endometrial
scratching and an increased chance of
pregnancy was first described a
decade ago, although the underlying
mechanism remains unknown.
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The new study involved 158 women who had
previously had unsuccessful courses of
reproductive treatment and were taking an oral
contraceptive pill directly before treatment. The
women were randomly allocated to endometrial
scratching with a pipelle de Cornier or a sham
procedure 7-14 days before core ovarian
stimulation was started.
Thirty nine of 79 women (49%) in the endometrial
scratching group and 23 of 79 (29%) in the
control group achieved a clinical pregnancy (risk
ratio 1.83 (95% confidence interval 1.13 to
2.97)). There were 33 live births in the scratching
group (42%) and 18 (23%) in the control group
(risk ratio 1.7 (1.13 to 2.56)
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Endometrial scratching
Improves the clinical pregnancy rate in
women undergoing assisted reproductive
treatment, new research shows.
A Cochrane Library systematic review
published in 2012 concluded that the
technique doubled the chance of
pregnancy and live birth after in vitro
fertilisation (IVF) treatment but said that
more research was needed.
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Conclusion
Hysteroscopy in the management of
the infertile female remains under
debate.
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.
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Conclusion
The randomized trials do not clearly
demonstrate that surgical correction of
all intrauterine abnormalities improves
IVF outcome
observational studies suggest a benefit
for resection of submucosal leiomyomas,
adhesions, and endometrial polyps in
increasing pregnancy rates.
More randomised controlled studies are
needed to substantiate the effectiveness
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Conclusion
Hysteroscopy before starting IVF
treatment could increase the chance
of pregnancy in the subsequent IVF
cycle in women who had one or more
failed IVF cycles
Endometrial scratching Improves the
clinical pregnancy rate in women
undergoing assisted reproductive
treatment.
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