prof aboubakr elnashar

1. INDICATIONS
&
CONTRAINDICATIONS
OF
HYSTEROSCOPY
Prof.
Aboubakr
Elnashar
Benha
University
Hospital
ABOUBAKR
ELNASHAR
INTRODUCTION

Hysteroscopy

Visualization
of
the
cavity
of
the
uterus
using
a
camera.

Very
useful
tool
for
a
variety
of
problems
presenting
to
a
gynecologist/infertility
specialist

Can
be
used
both
for
diagnostic
&
curative
purposes.

Diagnostic
hysteroscopy
alone
is
not
logical
and
should
be
followed
by
corrective
procedures
in
the
same
sitting:
saves
time,
cost,
as
well
as
exposure
to
repeated
anesthesia

Visualization
is
best
in
immediate
post-menstrual
period
but
can
be
performed
in
any
phase
of
menstrual
cycle
ABOUBAKR
ELNASHAR

2. Diagnostic
Hysteroscopy
It
can
be
performed
in
two
ways:
1.
Conventional
Inpatient
Approach
(classic
technique)

Done
under
anesthesia

inserting
a
vaginal
speculum
to
visualize
the
cervix,
dilating
the
cervix
with
serial
Hegar
dilators,
sounding
the
canal
for
uterocervical
length,
and
then
inserting
the
hysteroscope.

Liquid
distension
medium:
normal
saline
to
distend
cavity.
ABOUBAKR
ELNASHAR
2.
Modern
Office
Hysteroscopy
(vaginocervico
hysteroscopy
or
“no-touch”
technique)

uses
mini
hysteroscopes.

speculum
and
dilators
are
not
used.

Hysteroscope
is
introduced
in
the
vaginal
introitus,
and
a
low-viscosity
liquid
distension
medium
(normal
saline)
is
allowed
to
distend
the
vagina.

This
facilitates
the
direct
visualization
of
external
cervical
os
and
with
a
narrow
diameter
scope;
uterine
cavity
can
be
entered
without
cervical
dilatation.
ABOUBAKR
ELNASHAR

3. 
requires
skill
and
can
be
performed
in
majority
of
patients
without
any
discomfort
with
a
success
rate
of
over
90%.

However,
presence
of
cervical
stenosis
is
a
contraindication

Further
advantage
of
office
hysteroscopy
is
that
the
physical
examination,
TVS,
and
hysteroscopy
can
be
combined
in
one
outpatient
sitting.

Immediately
after
the
hysteroscopy,
a
second
TVS
can
be
performed
taking
advantage
of
the
intracavitary
fluid
for
a
contrast
image
of
the
uterus
just
like
in
sonohysterosalpingogram.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

4. RCOG
classification
of
operative
hysteroscopy
levels
Level
1
•Diagnostic
hysteroscopy
with
target
biopsy
•Removal
of
simple
polyps
•Removal
of
intrauterine
contraceptive
device
Level
2
•Proximal
fallopian
tube
cannulation
•Minor
Asherman's
syndrome
•Removal
of
pedunculated
fibroid
(type
0)
or
large
polyp
Level
3
•Division/resection
of
uterine
septum
•Major
Asherman's
syndrome
•Endometrial
resection
or
ablation
•Resection
of
submucous
fibroid
(type
1
or
type
2)
•Repeat
endometrial
ablation
or
resection
ABOUBAKR
ELNASHAR

Wide
spread
use
of
hysteroscopy
1.
Increased
clinician
training
2.
Smaller
diameter
hysteroscopes
3.
Increased
emphasis
on
office-based
procedures
ABOUBAKR
ELNASHAR

5. ABOUBAKR
ELNASHAR
INDICATIONS
FOR
HYSTEROSCOPY
Hysteroscopy
is
performed
for
evaluation
or
treatment
of
the
endometrial
cavity,
tubal
ostia,
or
endocervical
canal
in
women
with:
1.
Space-Occupying
Lesion
(SOL)
on
US
or
Filling
Defect
on
HSG

Such
a
shadow
can
be
due
to
either
1.
endometrial
polyp
or
2.
fibroid
or
3.
intrauterine
synechiae.

Hysteroscopy
remains
the
gold
standard
for
diagnosis
of
such
problems
with
an
added
advantage
that
correction
can
be
done
in
the
same
sitting.
ABOUBAKR
ELNASHAR

6. 1
Endometrial
Polyp

Seen
as
localized
filling
defect
in
the
cavity
on
HSG
and
as
SOL
on
US.

Can
be
functional
or
nonfunctional

Seen
in
patients
receiving
tamoxifen
for
breast
cancer.

On
hysteroscopy

Nonfunctional
polyps:
white
protuberances
with
branching
fine
vessels
on
the
surface

Functional
polyps:
smaller
and
look
similar
to
the
surrounding
endometrium.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

7. 
Hysteroscopic
removal
of
polyps

Far
superior
compared
to
blind
curettage
as
the
latter
can
result
in
incomplete
removal
in
many
cases

The
most
effective
management
for
endometrial
polyps

Allows
histologic
assessment,
whereas
blind
biopsy
or
curettage
has
low
diagnostic
accuracy
and
should
not
be
performed
pedunculated
vascular
endometrial
polyp
on
hysteroscopy
ABOUBAKR
ELNASHAR
2
Myoma

classified
in
various
ways:
1.
Sessile
or
pedunculated
as
per
the
absence
or
presence
of
stalk
2.
According
to
the
location
with
respect
to
cavity
(European
Society
of
Gynecological
Endoscopy)
Type
0
myomas

entirely
within
the
uterine
cavity

white
spherical
masses
with
a
network
of
thin
fragile
vessels
on
surface

can
be
dealt
easily
using
a
hysteroscopic
scissors/resectoscope.
ABOUBAKR
ELNASHAR

8. ABOUBAKR
ELNASHAR
Type
1
myomas

≥50%
in
the
cavity
and
partially
embedded
in
the
myometrium

The
intracavitary
part
can
be
removed
using
loop
on
resectoscope
or
a
hysteroscopic
morcellator.

For
deep-seated
big
myomas
requiring
extensive
resection,
laparoscopic/USG
guidance.

Complete
resection
might
require
more
than
one
procedure
in
large
myomas.

Nd:YAG
(neodymium:yttrium
aluminum
garnet)
laser/radio
frequency
electrodesiccation
may
be
needed
for
destroying
the
remaining
portion
of
myoma.
ABOUBAKR
ELNASHAR

9. Type
2
myomas

deep-seated
with
<50%
component
in
the
cavity.

removed
through
laparoscopy
or
laparotomy.

Best
results
are
seen
in
myomas
which
are
5
cm
or
less
in
diameter
and
entirely
intracavitary
(Type
0)
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

10. 3.
Intrauterine
Synechiae

Most
common
causes:
trauma
or
infection
such
as
TB
or
an
estrogen-deprived
environment
as
in
abortion/PPH

TB
affecting
endometrium:
varying
degree
of
synechiae
obliterating
the
uterine
cavity.

HSG:
filling
defects
which
may
vary
from
minimal
to
severe
and
obliterate
the
endometrial
cavity
partially
or
completely

Hysteroscopic
resection
of
thick
synechiae

technically
challenging
surgery
{multiple
vascular
channels
are
opened
up
on
cutting
the
band}:
increases
the
chances
of
IV
absorption
of
distending
medium
which
in
case
of
glycine:
life-threatening
complications.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

11. 
Complete
removal
of
extensive
adhesions
may
require

Repeated
procedures

Check
hysteroscopy
after
an
adhesiolysis
procedure.

Hysteroscopic
adhesiolysis:

conception
rate
of
44.3%

live
birthrate
of
86.1%

no
conception
in
patients
who
needed
repeat
adhesiolysis.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

12. AAGL
Guidelines,
2017
•
Hysteroscopic
guidance
is
the
method
of
choice
with
any
tool.
Level
B
•
No
role
of
blind
cervical
probing
or
D/C.
Level
C
•
Laparoscopy
may
be
combined
in
cases
of
dense
and
lateral
adhesions.
•
Estrogens
can
be
used
to
prevent
recurrence.
•
Reassessment
of
cavity
after
2
to
3
cycles
with
HSG
or
office
hysteroscopy
•
For
women
with
IUAs
who
do
not
wish
any
intervention
but
still
want
to
conceive,
expectant
management
may
result
in
subsequent
pregnancy;
however,
the
time
interval
may
be
prolonged.
Level
C.
ABOUBAKR
ELNASHAR
2.
Abnormal
Uterine
Bleeding
(AUB)

Indications:
•
Excessive
amount
or
duration
of
bleeding,
commonly
in
women
of
age
40
years
or
more
•
Excessive
bleeding
not
responsive
to
medical
therapy
even
in
women
of
age
<40
years
•
Intermenstrual
bleeding
with
a
normal
cervical
smear
•
Postcoital
bleeding
with
a
normal
cervical
smear
•
Postmenopausal
bleeding
or
endometrial
thickness
of
≥4
mm
in
a
postmenopausal
lady
•
Oligomenorrhea
or
amenorrhea
in
reproductive
age
group
ABOUBAKR
ELNASHAR

13. Hysteroscopy
1.
helps
in
making
a
diagnosis
as
well
as
in
taking
a
targeted
biopsy
from
a
suspicious
area.
2.
In
cases
of
thick
endometrium
where
malignancy
has
been
ruled
out,
hysteroscopic
endometrial
resection
(TCRE)
can
cure
the
problem:
avoiding
a
potential
hysterectomy.
This
procedure
is
not
suitable
for
women
desiring
fertility
in
the
future
3.
For
a
woman
in
reproductive
age
group,
oligomenorrhea
or
amenorrhea
is
usually
due
to
IU
synechiae
or
atrophic
endometrium.
These
can
be
diagnosed
as
well
as
cured
with
hysteroscopy.
ABOUBAKR
ELNASHAR
3.
Congenital
Uterine
Anomalies

The
commonest:
complete
or
partial
uterine
septum,
bicornuate
uterus,
uterus
didelphys,
transverse
vag
septum

Most
of
them
can
be
picked
up
on
an
HSG
but
it
is
difficult
to
dd
a
septum
from
a
bicornuate
uterus
on
imaging.

3
DUS
&
MRI
has
a
high
accuracy

These
anomalies
can
cause
recurrent
pregnancy
loss
or
preterm
labor,
whereas
a
transverse
vaginal
septum
can
cause
infertility.

Resection
of
uterine
septum

using
scissors/resectoscope/Nd:YAG
laser.

The
septum
is
cut
from
below
and
upward.
ABOUBAKR
ELNASHAR

14. ABOUBAKR
ELNASHAR
Cochrane
Review,
2017
•
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
Fig.
3.9
(a–d)
Hysteroscopic
resection
of
the
septum
from
one
end
to
the
other
using
Collin’s
knife

Uterine
septum
ABOUBAKR
ELNASHAR

15. (1)
submucous
myoma,
(2,
3)
endometrial
polyp,
(4)
uterine
septum,(5)
intrauterine
adhesions,
(6)
placental
remnants.
ABOUBAKR
ELNASHAR
5.
Recurrent
Pregnancy
Loss
(RPL)

RPL
caused
by
anatomic
abnormalities
of
the
cervix
or
uterine
cavity.
These
may
be
either
congenital
or
acquired.

Congenital:
mullerian
duct
fusion
abnormalities,
the
commonest
of
which
are
incomplete
uterine
septum
and
abnormalities
caused
by
in
utero
DES
exposure.

Acquired:
IU
adhesions,
myoma,
and
endometritis.
These
may
not
be
picked
up
on
US
or
HSG
many
times.

1
st
T
losses
are
mainly
due
to
abnormal
placentation.
The
endometrium
overlying
these
lesions
is
poorly
developed:
poor
vascularization
of
placenta.

Hysteroscopic
correction:
improve
pregnancy
outcome
ABOUBAKR
ELNASHAR

16. 6.
Cannulation
of
the
Fallopian
Tubes

For
treating
interstitial
obstruction
due
to
mucus
plug
or
debris
or
spasm.

This
procedure
is
combined
with
laparoscopy.

A
Teflon
cannula
with
a
metal
obturator
is
introduced
through
operating
channel
of
the
hysteroscopic
sheath
and
gently
advanced
through
the
tubal
ostia
till
resistance
is
encountered
or
till
cornua
is
reached.

The
obturator
is
then
withdrawn&
dye
is
injected
through
the
catheter.

Mucus
plug
or
debris
or
thin
adhesions
get
dislodged
by
pressure,
and
the
flow
of
dye
through
the
fimbrial
end
can
be
seen
simultaneously
through
the
laparoscope.
ABOUBAKR
ELNASHAR
Proximal
tubal
block
Ureteric
catheter
of
3.5–5
Fr
can
be
used
for
cannulation
Hysteroscopic
cannulation
of
ostium
ABOUBAKR
ELNASHAR

17. Proximal
Tubal
Blockage
(PTB)
•
Accounts
for
approximately
15%
of
cases
of
tubal
factor
infertility
40%:Salpingitis
isthmica
nodosa
(SIN)
10%:
Endometriosis
Cornual
Polyp
20%:
Cornual
Spasm
30%:
Stromal
Oedema
Tubal
debris
Intraluminal
adhesions
Viscid
Secretion
•
Suresh
YN,
Narvekar
NN.
TOG
2014;16:37–45.
ABOUBAKR
ELNASHAR
7.
Hysteroscopic
Tubal
Sterilization

using
a
micro
insert
consisting
of
soft
stainless
steel
inner
coil
and
a
dynamic
nickel-titanium
alloy
outer
coil
known
as
Essure.

The
device
is
introduced
into
the
uterus
with
a
5
mm
operating
channel
hysteroscope
and
guided
into
the
proximal
section
of
the
fallopian
tube
at
the
uterotubal
junction.

Fibrous
tissue
grows
into
it
with
time
occluding
the
tubes
permanently.
ABOUBAKR
ELNASHAR

18. Essure
device
(Source:
Radiographic
Findings
and
patient
evaluation
in
irreversible
fallopian
tube
occlusion
contraceptive
device
Essure;
EPOS™;
ECR
2014/C-0576;
reproduced
with
permission
from
Javier
Azpeitia
Armán)
ABOUBAKR
ELNASHAR
Essure
device
before
placement
(left)
and
after
placement
with
five
coils
trailing
in
cavity
(right)
ABOUBAKR
ELNASHAR

19. 8.
Treatment
of
Missed
Abortion/Retained
Products
of
Conception

When
an
early
1
st
T
pregnancy
termination
fails
and
histological
examination
of
the
products
of
conception
does
not
demonstrate
chorionic
villi,
an
ectopic
pregnancy
should
be
suspected,
particularly
if
the
pregnancy
test
is
persistently
positive.
In
such
a
case,
when
laparoscopy
fails
to
demonstrate
tubal/ovarian/peritoneal
pathology
consistent
with
an
ectopic
pregnancy,
hysteroscopy
may
be
of
value.

The
reason
may
be
early
gestation
in
an
anomalous
uterus,
such
as
a
septate
uterus
with
an
early
pregnancy
at
a
site
that
was
not
curetted.

Hysteroscopy
can
guide
selective
suction
aspiration
for
termination
of
the
missed
pregnancy.
This
approach
has
been
greatly
facilitated
with
the
use
of
concomitant
sonography.
ABOUBAKR
ELNASHAR
Retained
products
of
conception.
ABOUBAKR
ELNASHAR

20. 9.
Removal
of
Impacted
or
Lost
IUCD

Sometimes
the
thread
of
an
IUCD
is
not
visible
in
the
vagina.

Such
a
lost
IUCD
or
an
impacted
foreign
body
can
be
removed
using
a
specially
designed
hook
or
a
toothed
curette
under
hysteroscopic
guidance
ABOUBAKR
ELNASHAR
Absolute
Contraindications

where
this
procedure
should
not
be
performed
at
all.

If
it
is
performed,
there
is
a
very
high
risk
to
the
patient.
1.
Presence
of
IU
pregnancy
which
has
a
very
high
possibility
of
getting
the
fetus
misplaced
and
getting
aborted.
2.
In
cases
of
an
active
genital
infection
and
cancer,
the
disease
can
get
disseminated.
Since
the
flow
of
fluid
distension
medium
is
from
the
uterine
cavity
through
the
fallopian
tubes
into
peritoneal
cavity,
it
can
carry
the
infectious
microorganism/cancerous
cells
along
with
leading
to
dissemination.
ABOUBAKR
ELNASHAR

21. Relative
Contraindications

where
the
procedure
may
cause
harm
or
may
be
inconclusive.
1.
In
cases
of
heavy
uterine
bleeding,
it
may
not
be
possible
to
see
anything
at
all
except
blood,
and
the
procedure
becomes
inconclusive.
2.
An
inexperienced
surgeon
may
not
be
able
to
maneuver
the
equipment
properly
and
may
cause
a
perforation
3.
In
case
of
cardiovascular
disease,
fluid
overload,
more
so
high
viscosity
fluid
during
operative
procedure,
can
become
life
threatening.
One
has
to
keep
a
careful
record
of
fluid
input,
output,
and
fluid
balance.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

22. CONCLUSION

Hysteroscopy
is
indicated
in
any
situation
in
which
an
intrauterine
pathology
is
suspected.

It
provides
direct
visualization
of
the
uterine
cavity
and
remains
the
gold
standard
for
diagnosis
and
treatment
of
these
lesions

Since
it
can
be
performed
in
office,
it
may
be
offered
as
a
first-
line
diagnostic
tool
for
evaluation
of
uterine
cavity
in
patients
with
abnormal
uterine
bleeding
and
infertility.

As
an
office
procedure,
the
combination
of
TVS,
hysteroscopy,
and
contrast
sonography
is
the
most
powerful
screening
tool
for
detecting
intracavitary
abnormalities.
ABOUBAKR
ELNASHAR