Page 5 - World Journal of Laparoscopic Surgery

Hysteroscopy and Assisted Reproductive Technology

All trials comparing the outcome of IVF treatment performed according to patient parity and surgeon’s previous experience.
in patients who had outpatient hysteroscopy in the cycle The indications for hysteroscopy were infertility in 219 cases
preceding their IVF treatment with a control group in which (46%). The pain experienced during the procedure (0-10), the
hysteroscopy was not performed were included. The main quality of visualization of the uterine cavity (0-3) and the
outcome measure was pregnancy rate. In total, 1691 participants complications were recorded. The examination was considered
were included in two randomized (n = 941) and three non- successful when the pain score was < 4, visualization score
randomized controlled studies (n = 750). The quality of the was >1 and no complication occurred. Less pain, better
studies was variable. Meta-analyses of the results of five studies visualization and higher success rates were observed with mini-
showed evidence of benefit from outpatient hysteroscopy in hysteroscopy (P < 0.0001, P < 0.0001 and P < 0.0001,
improving the pregnancy rate in the subsequent IVF cycle respectively), in patients with vaginal deliveries (P < 0.0001, P <
(pooled relative risk = 1.75, 95% CI 1.51-2.03). The evidence 0.0001 and P < 0.0001, respectively) and in procedures performed
from randomized trials was consistent with that from non- by experienced surgeons (P 5 0.02, P 5 NS and P 5 NS,
randomized controlled studies. 16 respectively). The effects of patient parity and surgeon
Thus, these studies along with the prevalence figures experience were no longer important when minihysteroscopy
provide strong evidence for including diagnostic hysteroscopy was used. They concluded that minihysteroscopy can be
as part of the primary investigation of infertile couple planned offered as a first line office diagnostic procedure. 4
for assisted conception. Future robust randomized trials
comparing outpatient hysteroscopy or minihysteroscopy with Hysteroscopic Surgery in Assisted Reproduction
no intervention before IVF treatment would be a useful addition Operative hysteroscopy has been accepted progressively as
to further guide clinical practice. 16 the best option for the treatment of intrauterine pathologies
such as polyps, submucous myomas, septum and adhesions. 1,4,6
Office Hysteroscopy versus Conventional In this respect, hysteroscopic surgery has replaced conventional
Hysteroscopy abdominal surgery. Surgical hysteroscopy is used to treat these
Although diagnostic and operative laparoscopy are well- anomalies and the patients receive general anesthesia. A high-
established in gynecology, diagnostic hysteroscopy is, frequency, low-voltage electric current is used, and glycine for
however, not widely used in the office setting because of the irrigation when using unipolar electrosurgical sources. This
discomfort produced by the procedure. Indeed, conventional procedure allows resection of submucous myomas and polyps
hysteroscopy was more commonly practised and is performed and of septa and adhesions. Some groups use laser beams and
under general anesthesia with a 4 mm optic with 5 mm external irrigation by physiological saline for these treatments.
sheath, speculum and tenaculum to grasp and fix the uterus Coagulation of a superficial focal spot of adenomyosis is not
1
and it sometimes requires cervical dilatation. Since it seems useful in infertility therapy. There were not many publications
invasive, traumatic and painful it is not very widely accepable. 4 addressing surgical hysteroscopy specifically in the assisted
Current evidence seems to weight heavily in favour of office reproduction, most studies address it in the wider context of
hysteroscopy. managing infertility.
All of the prospective studies on diagnostic hysteroscopy Hysteroscopic Metroplasty for Uterine Septum
in this review were done as office procedures in all cases or for
most. 3,10,11,13-15 This implies the pre-eminence of office The aim of metroplasty is to restore a normal uterine anatomy to
hysteroscopy in recent practice. Isaacson in a review, suggested improve obstetrical outcomes in some uterine malformations.
that the under utilization of office diagnostic hysteroscopy The hysteroscopic septoplasty cures the septate uterus. It is
denies many women a technique that is likely to keep them from an effective procedure in the case of uterine septum with
more invasive and less useful procedures, such as diagnostic recurrent abortion losses. It probably improves the rate of live
hysteroscopy and dilatation and curettage performed in the birth in women without obstetrical antecedent. For some authors,
operating room under general anesthesia. 2 it could be considered at the time of the diagnosis and as first-
The prospective series by DePlacido et al concluded that line treatment in an assisted reproductive techniques (ART)
Office minihysteroscopy is a very effective diagnostic tool in program. 17
an infertility work-up and is more widely accepted than Hysteroscopic resection of the septum improves fecundity
traditional hysteroscopy. 13 of women with septate uterus and otherwise unexplained
In the multicenter RCT by Rudi Campo et al, Patients were infertility. Patients with septate uterus and no other cause of
randomly assigned to undergo office diagnostic hysteroscopy sterility have a significantly higher probability of conceiving
either with 5.0 mm conventional instruments (n 5 240) or with after removal of the septum than patients affected by idiopathic
3.5 mm mini-instruments (n 5 240). Procedures were stratified sterility. 18

World Journal of Laparoscopic Surgery, September-December 2009;2(3):1-9 3