However, hysteroscopes that require minimal cervical dilation and yet still allow for an operative channel are available. Patient tolerance of hysteroscopes up to 5 mm allows for their use in an office setting where anesthesia is not required. Additionally, office-based hysteroscopy is no more costly than HSG at many institutions. Although SHG may offer a cost reduction, for the many patients in whom pathology is found or suspected, a hysteroscopy is then indicated adding expense, delay, and inconvenience. Furthermore, if HSG or SHG misses pathology, the cost of a first-line hysteroscopy that would have detected and treated such pathology pales in comparison to the expense of a failed IVF cycle.
When evaluating a patient prior to IVF, examination of the uterine cavity should be performed in the most accurate manner. The high incidence of endometrial polyps in our patient population may be related to multiple factors.
Prior therapy with gonadotropins exposes patients to higher levels of estrogen. These elevated estrogen levels may predispose women to the development of endometrial polyps. In the context of IVF, lower pregnancy rates have been reported in the presence of uterine cavity abnormalities, 9 — 11 and their correction has been associated with improved pregnancy rates.
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Outpatient hysteroscopy has been shown to be easily performed with excellent surgical results in previous studies. We were able to perform all diagnostic and operative procedures undertaken in the office setting. The initial office transvaginal ultrasound allowed us to exclude patients with large fibroids greater than 1. Additionally, by using a 5-mm hysteroscope with a 5 F operative channel, all of the desired instruments for operative correction can be used.
Grasping forceps allow for targeted removal of polyps with the ability to retain a clean specimen for pathologic confirmation. Scissors can be introduced for adhesions and septi. The coaxial bipolar electrode with a choice of differing tips allows for detailed uterine work, especially in removing submucous fibroids. By using the cutting mode primarily, and the desiccation mode when specific blood vessels are encountered, preservation of the delicate endometrium can occur while minimizing the risk of postoperative adhesions.
Office-based operative hysteroscopy has also been found to be extremely safe. In our study, no complications occurred, and no patients needed extended monitoring or laboratory studies for fluid overload. Typical complications associated with hysteroscopy may be procedure-related, media-related, or postprocedure related.
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Asking the patient to have a full bladder also helps to straighten the cervico-uterine canal to facilitate entry in patients with an anteverted uterus. For the rare patient with a difficult entry, concurrent ultrasound guidance can be invaluable. Our clinic has an ultrasound machine located in the procedure room and readily available. Using saline as the distention medium also serves to minimize and often to eliminate medium-related complications. Hyponatremia and cerebral edema are more of a concern when using hypotonic, electrolyte-free media, such as glycine or sorbitol.
But as several authors 14 , 18 point out, fluid overload, pulmonary edema, and congestive heart failure can still occur if an excessive volume of saline is used, especially if patients have underlying medical conditions predisposing them to fluid-related complications. Air embolism is also a potential complication that must be considered.
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By avoiding the Trendelenburg position, excessive fluid pressure, prolonged operative times, a dilated cervix without instruments sealing air entry, and by purging the tubing of air, the risk of embolism is minimal. Postprocedure complications like endometritis can be reduced or eliminated by pre- and posttreatment with antibiotics, as we do in our clinic, and by avoiding operating on patients with active vaginal infections.
Additional benefits of operative hysteroscopy have also been proposed. Cervical dilatation may facilitate embryo transfer and the introduction of insemination catheters. McManus et al 19 found this to be the case if cervical dilatation was performed on average 31 days before embryo transfer.
Background and Objectives:
However, in a previous study at our institution, operative hysteroscopy in the cycle prior to embryo transfer did not alter the percentage of transfers that changed from difficult to easy although it was associated with a higher pregnancy rate. The increase in pregnancy rates was attributed to the removal of endometrial polyps or polypoid endometrium at the time of hysteroscopy and thus improving implantation in this population at risk.
Regardless of whether these adjunctive benefits are confirmed by further study, office-based operative hysteroscopy still holds value as the gold standard of diagnostic procedures for uterine cavity abnormalities with the ease, safety, and efficiency of simultaneous therapeutic correction of abnormalities. In an infertile population where hysteroscopy is performed routinely prior to IVF, a significant percentage of patients are found to have uterine pathology. Endometrial polyps are found most frequently, with smaller numbers of fibroids, adhesions, retained products of conception, and septi.
These abnormalities may impair the success of future treatment cycles, and removal of the pathology is recommended.
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Patient tolerance and the feasibility of operative management, simultaneous with diagnosis, make office-based operative hysteroscopy an ideal first-line procedure with minimal risk to the patient. National Center for Biotechnology Information , U. Hinckley , MD and Amin A. Address reprint requests to: This article has been cited by other articles in PMC. Abstract Background and Objectives: Reproductive surgery, Hysteroscopy, In vitro fertilization, Endometrial polyps.
Open in a separate window. Uterine evaluation by microhysteroscopy in IVF candidates.
Clinical experience with infertile patients. Acta Obstet Gynecol Scand. Comparison of hysterosalpingography and hysteroscopy in female infertility. J Am Assoc Gynecol Laparosc. Hysteroscopy is superior to hysterosalpingography in infertility investigation. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: Sonohysterography versus hysteroscopy for diagnosing endouterine abnormalities in fertile women.
Int J Gynaecol Obstet. Effect of hysteroscopy performed in the cycle preceding controlled ovarian hyperstimulation on the outcome of in vitro fertilization. Narayan R, Rajat, Goswamy K. Treatment of submucous fibroids, and outcome of assisted conception. Office-Based Infertility Practice is an invaluable resource to all physicians treating infertile couples.
1000 Office-Based Hysteroscopies Prior to In Vitro Fertilization: Feasibility and Findings
The most current and advanced therapies available are discussed by recognized experts in the field. The first half of the book is devoted to the evaluation and work-up of the infertile couple, including evaluation of the male, female, age-related infertility factors, and the roles of ultrasound, endometrium saline sonography, falloposcopy and diagnostic laparoscopy and hysteroscopy. The second half of the book presents the treatment and operative procedures for the infertile couple, including ovulation induction, IUI, tubal cannulation, treatment of cervical stenosis, the use of office laparoscopy and therapeutic hysteroscopy, male treatment as support for IVF, vas reversals, and testicular biopsy, as well as routine IVF, intratubal gamete transfer, and micromanipulation.
With over 60 illustrations, this book is a must for all infertility specialists, obstetrician-gynecologists, fellows, and residents. Its practical, comprehensive approach will be of daily use to the office practitioner treating women of reproductive age. Role of Ultrasonography in Infertility. Ovulation Induction and Controlled Ovarian Hyperstimulation with.