Tatjana Motrenko, Human Reproduction Centre, Budva, Montenegro
There is several groups of uterine cavity defects, mainly divided in following groups according origin: Mullerian tract anomalies, muscular tissue diseases (subserous myomas and adenomyosis), endometrial pathology (endometritis, adhesions, polyps). After initial diagnosis mainly reached by ultrasonography, the best way to have final diagnosis and in same time correct it is hysteroscopy. The question still remains in case of infertile patients what out of mentioned should be corrected in order to increase chance for pregnancy.
Hysteroscopy is endoscopic procedure using transcervical approach to view and operate in uterine cavity. As a minimal invasive intervention could be used for outpatient, providing diagnosis and treatment for endocervical and intrauterine pathology, like polyps, adhesions, myoma’s etc. There are two kinds, rigid and flexible hysteroscopes, with different diameter and additional instruments. Also, two kind of electricity power could be used-monopolar and bipolar, with different extensional media (gas or fluids), for monopolar electricity nonconductive, and for bipolar conductive media.
All of the patients with infertility problems passed very detail diagnostic procedures, and repeated ultrasonography, where most of intrauterine pathology could be diagnosed. Before we proceed to any infertility treatment procedure, it is obvious that we have to solve first existing problems and hysteroscopy is logical choice. But still is a question do we have to provide hysteroscopy for all patients as part routine infertility workup or it is reserved for selected cases of cavity defects and which on? Does hysteroscopy before IVF and IUI bring benefit to patients and increase success of assisted reproductive technologies? Or do we have to do it in patients without visible pathology before MAR? And do we have to repeat in specific time related to planed ovarian stimulation or IVF cycle start? Insight study shows that there is no difference in pregnancy rate if we do hysteroscopy for patients without US visible pathology comparing with group without hysteroscopy, but we have to ask ourselves about quality of hysteroscopy performance and operators skills, as well as about proper diagnosis and interventions, since 10% of hysteroscopy couldn’t be performed at all until end.
Since main goal of hysteroscopy is to diagnose and remove intrauterine pathology, group of J.Bosteels made a systematic review of studies conducted about effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynecological problems. Analysis of 30 relevant publications was made and the evidence yielded by hysteroscopy in subfertile population summarized. Only randomized and controlled studies were included in review, using QOURUM and MOOSE guidelines. Hysteroscopy removal of endometrial polyps doubled pregnancy rate in IUI in next 3 months compared with diagnostic hysteroscopy and polyp biopsy.
There was marginally significant benefit from removal fibroids smaller than 4 cm (submucous fibroids with or without intramural fibroids). Hysteroscopy metroplasty improve results in RPL, but less in subfertility group. For intrauterine adhesions proper studies are lacking, mainly because diversity on adhesion extension and hysteroscopy repeating several times. Tomasevic study related to hysteroscopy correction of Mullerin tract anomalies in patients with unsuccessful IVF resulted in doubling pregnancy rate in IVF after intervention. There are some studies related to endometrial polyps, pointed that size of polyps play role, and if it is below 1 or 1,5cm (depend of study) it will not jeopardize treatment result and it is not needed to be removed.
Obviously, current practice is that all patients for infertility treatment, eider IUI or IVF with US diagnosed intrauterine pathology will have hysteroscopy before IVF, but it is still ongoing debate do we have to do hysteroscopy in case of repeated implantation failure in light of recent Trophy RCT. Still, even in this study, they find about 12 % of unrecognized major intrauterine pathology and 11% of minor changes. Also, patients with no previous hysteroscopy benefit from it (centers from UK)- better CPR, comparing with patients from Art centers from continent, where majority of them had previously hysteroscopy but more than 6 months before study enrollment.