Page 9 - World Journal of Laparoscopic Surgery

Hysteroscopy and Assisted Reproductive Technology

that the incidence of uterine synechiae after bipolar pregnant women gave birth at term, while the other two
hysteroscopic resection of fibroids was 7.5%. This appears to pregnancies are still ongoing. They concluded that, with no
be lower than that reported in previous studies using monopolar consensus regarding the management of patients diagnosed
energy. 32 with endometrial polyp in IVF cycles. Cryopreservation, cycle
Thus, bipolar hysteroscopic myomectomy may be a better cancellation and embryo transfer preceding polypectomy is the
option for infertile women. It must be said, however, that drawing current management choice. 34
clear guidelines for the management of fibroids in infertile women Madani et al in a similar series studied nine patients who
is difficult due to the lack of large randomized trials aimed at underwent assisted reproduction treatment cycles and were
elucidating which patients may benefit from surgery. 32 diagnosed with endometrial polyps less than 1.5 cm by
transvaginal ultrasonography. Eight patients were treated by
Hysteroscopic Management of Endometrial Polyps long protocol and one patient was the recipient of an egg
donation cycle. In all patients, polyp resection was performed
There were very few studies addressing hysteroscopic
polypectomy in assisted reproduction and there is no through hysteroscopic polypectomy. Polypectomy was done
consensus about the management of patients diagnosed with during ovarian stimulation in the standard treatment cycles,
endometrial polyp in IVF cycles. and during hormone replacement therapy in the recipient of the
Lass and colleagues at Bourn Hall Clinic Cambridge egg donation cycle. The interval between polyp resection and
investigated the effect of endometrial polyps on pregnancy embryo transfer was 2-16 days. Four patients achieved
outcome in an in vitro fertilization (IVF) program. Endometrial pregnancy (two twins, two singletons), four patients were
polyps less than 2 cm in diameter were suspected by transvaginal unsuccessful, and one pregnancy was a blighted ovum. All of
ultrasound before oocyte recovery in 83 patients. Forty-nine the successful pregnancies were still ongoing. At time of
women (Group I) had standard IVF-embryo transfer, while in 34 publication. They concluded that if polypectomy before embryo
women (Group II) hysteroscopy and polypectomy were transfer in an IVF cycle is proven to be safe, then embryos will
performed immediately following oocyte retrieval, the suitable be transferred without cycle cancellation. And that since this
embryos were all frozen, and the replacement cycle took place a study included nine patients; further studies with more patients
35
few months later. Of the 32 hysteroscopies, a polyp was are required to confirm these findings.
diagnosed in 24 cases (75%) and polypoid endometrium in In a different scenario, Perez-Medina and colleagues carried
another 5 patients (15.6%). An endometrial polyp was confirmed out a prospective randomized study to determine whether

by histopathological examination in 14 women (58.3%). The hysteroscopic polypectomy before intrauterine insemination

pregnancy rate in group I was similar to the general pregnancy (IUI) achievedbetter pregnancy outcomes than no intervention.

rate of our unit over the same period (22.4 vs 23.4%) but the A total of 215 infertile women from the infertility unit of a

miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, universitytertiary hospital with ultrasonographically diagnosed

the pregnancy and miscarriage rates were similar to those of the endometrialpolyps (EP) undergoing IUI were randomly allocated

frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and to one of two pretreatment groups using an opaque envelope

12.1%, respectively).Their conclusion was that small endometrial technique with assignment determined by a random number

polyps, less than 2 cm, do not decrease the pregnancy rate, but table. Hysteroscopic polypectomy was performed in the study

there is a trend toward increased pregnancy loss. A policy of group. Diagnostic hysteroscopy and polyp biopsy was

oocyte retrieval, polypectomy, freezing the embryos, and performed in the control group.Total pregnancy rates and time

replacing them in the future might increase the “take-home baby” for success in both groups afterfour IUI cycles were compared

rate. 33 by means of contingency tables and life-table analysis. A total

Batioglu and Kavmak in a prospective series reported 6 of 93 pregnancies occurred,64 in the study group and 29 in the

patients with endometrial polyp (measuring < 2 cm) diagnosed control group. Women in the study group had a better

by transvaginal ultrasonography performed on days 7 and 9 of possibility of becoming pregnant after polypectomy, with a

the cycle in patients who underwent IVF. These six patients relative risk of 2.1 (95% confidenceinterval 1.5-2.9). Pregnancies

were treated by hysteroscopic polypectomy preceding oocyte in the study group were obtained before the first IUI in 65% of
retrieval under general anesthesia after informed consent was cases. Their conclusion is that hysteroscopic polypectomy
36

obtained. The cause of infertility was male factor in three before IUIis an effective measure.
patients, tubal factor in one, and two cases were unexplained.
All patients had undergone ovulation induction and luteal Implications for Sub Saharan Africa
support according to the long luteal protocol. As a result, in Diagnostic and operative hysteroscopy are not used equally
three cases pregnancy was achieved (one multiple and two worldwide, neither is the practice of assisted reproductive
singleton) and three cases were unsuccessful. One of the techniques. There were no studies accessed on hysteroscopy
World Journal of Laparoscopic Surgery, September-December 2009;2(3):1-9 7