Compliance and diagnostic efficacy of mini-hysteroscopy versus traditional hysteroscopy in infertility investigation

doi:10.1016/j.ejogrb.2007.02.028

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 135, Issue 1, November 2007, Pages 83-87

https://doi.org/10.1016/j.ejogrb.2007.02.028 Get rights and content

Abstract

Objective

The aim of this study was to compare traditional hysteroscopy with mini-hysteroscopy in terms of compliance, side effects and diagnostic efficacy.

Study design

We prospectively considered 950 female candidates for an IVF programme. All women underwent outpatient hysteroscopy; in 602 cases (Group A) a mini-hysteroscope was employed; in 348 women (Group B) a 5-mm hysteroscope was adopted.

Results

Cavity findings were similar in both groups. Endometrial polyps and uterine septum seem to be more frequent in our infertile patients than in the general population. No significant differences in terms of side effects were found between the groups. Mean visual analogue pain scale score was significantly lower in the patients of Group A than in those of Group B (p < 0.001).

Conclusions

Office mini-hysteroscopy is a very effective diagnostic tool in an infertility work-up and is more widely accepted than traditional hysteroscopy. Routine use of the technique should be considered.

Introduction

In cases when direct visualisation of the uterine cavity is required, hysteroscopy is the most effective diagnostic tool. Yet, its application in infertility investigation is controversial mainly because of the invasiveness of the technique. In the last few years, the progressive reduction in diameter of new hysteroscopes and the widespread diffusion of the technique made it feasible as a routine outpatient examination. By lowering the grade of pain experienced by patients during the procedure, mini-hysteroscopy could be routinely performed in all infertile women who are candidates for an assisted reproductive technique.

Another limitation that was traditionally linked to hysteroscopy use in infertility is the ongoing debate on the real influence of uterine pathology on fertility.

One of the most common findings in infertility patients is the presence of leiomyomata [1], [2]. It seems that mainly the location and dimensions of the myomata can affect fertility. Unfortunately, not many randomised controlled trials have been performed to compare conception rates in women with and without intra-uterine leiomyomata. Only one author [3] has compared spontaneous pregnancy rates in infertile women with and without myomas after excluding other causes of infertility. Conception rates were higher in women without myomas, and myomectomy significantly improved pregnancy rates, but the small sample size and the short-term follow-up indicated the need for other studies. Moreover, no relationship was evaluated between pregnancy rates and location of the myomas. In vitro fertilisation (IVF) itself represents an optimal model to study the effects of myomas on fertility. It is clear that submucosal or intramural fibroids that distort the endometrial cavity and are therefore visible at hysteroscopy adversely affect embryo implantation in IVF, and myomectomy should be considered [4], [5], [6]. There is some evidence that endometrial polyps might also affect embryo implantation, and thus hysteroscopic polypectomy performed prior to an assisted reproductive technique should be considered [7]. Anyway, there is no agreement on the dimension of polyps that might affect fertility, where polyps smaller than 2 cm seem not to decrease pregnancy rates [8], [9], but rather to worsen pregnancy trends [10].

A condition that is easily diagnosed by hysteroscopy and is known to affect embryo implantation is the presence of a Müllerian malformation, especially a septate uterus. Women with a uterine septum and no other known infertility factors might benefit from hysteroscopic metroplasty [11], [12], [13], [14].

The role of hysteroscopy in repeated implantation failures has also been debated; uterine cavity pathologies (including hyperplasia, polyps and synechiae) were detected in 18% of women with at least three previous unexplained IVF failures [15] and repeated hysteroscopy was advised in this group.

Traditional hysteroscopy is, in most cases, feasible in an office setting, although often not widely accepted by patients, due to pain elicitation during the procedure. Mini-hysteroscopy employs thinner instruments and saline solution infusion distension, becoming as minimally invasive as contrast sono-hysterography [16] and equally effective in the detection of intra-uterine pathologies [17].

The aim of this prospective observational study was to understand the diagnostic efficacy and compliance of mini-hysteroscopy in a standard infertility diagnostic work-up.

Section snippets

Patients

The Institutional Review Board approved the study design, which was conducted according to the guidelines of the Declaration of Helsinki (1975). A total of 950 infertile patients undergoing an outpatient hysteroscopy between February 2004 and May 2006 at the Infertility Unit of University “Federico II” in Naples were considered for this study. Inclusion criteria were: age < 39 years, no PAP smear or colposcopy anomalies, BMI < 27, no history of cardio-vascular disease, no evidence of cervical

Results

The anthropometric and anamnestic characteristics were comparable between groups and are reported in Table 1. The failure rate was 18 out of 602 (3%) in Group A and 22 out of 348 (6.3%) in Group B (p < 0.05). A vaginoscopic approach was adopted in 103 out of 602 women (17.1%) in Group A and in 56 out of 348 women (16%) in Group B.

The uterine cavity findings are shown in Table 2. A regular cavity was found in 388 out of 602 patients (64.4%) in Group A and in 210 out of 348 (60.3%) in Group B;

Discussion

Hysteroscopy is able to give precious information about the uterine cavity with regard to an in vitro fertilisation technique. Thus, notwithstanding, no practice guideline prescribes hysteroscopy as a mandatory diagnostic tool for infertility investigation, the ESHRE guidelines for infertility investigation [19] indicate hysteroscopy to be unnecessary unless for confirmation and treatment of doubtful uterine pathology, whereas the Royal College of Obstetricians and Gynaecologists [20] state

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2019, Encyclopedia of Biomedical Engineering
Hysteroscopy today is an essential tool in gynecology both for diagnosis of female upper genital tract abnormalities and for minimally invasive surgery procedures. It is safe, reliable and has few side effects and complications. Used without analgesia or anesthesia it has reduced hospitalization risks and made the examination affordable; it has a drawback which is the level of pain some women refer with instrumentation. Many attempts with the use of analgesics and anesthetics have been made to control pain with poor results; the new “hysteroscopic anesthesia” technique showed a statistical reduction of pain after injection and could become a practical solution in making hysteroscopy bearable in an office setting.
Development of an electronic endoscope for the diagnosis of uterine diseases without anesthetics
2015, Optik
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Moreover, the suffering of the patients can be relieved because of small outside diameter of electronic endoscope. Hence, electronic endoscope is being applied more and more widely in the clinical medicine [9]. One of the most important application fields of electronic endoscope is the early diagnosis of various malignant tumours in womb, including cervical cancer, ovarian cancer, endometrium cancer and so on [10–12].
A medical electronic endoscope with an outside diameter of 4.5 mm was developed for uterine cavity lesions examination without anesthetics. The electronic endoscope, with a flexible head of 270° turning angle and an optical imaging system of 100° field angle, realizes non-blind spot diagnosis. The effective focus length of the optical imaging system is 1.2 mm, the depth of field 10–100 mm, the maximum field curvature 0.1 mm, and the resolution capability of image system 145 cycles/mm. CCD image sensor is with a diagonal dimension of 1/10 in. and SVGA display model of 500 × 580 pixels. The illumination system uses the crescent-shaped optical fiber bundle as light transmission and metal halide lamps, high illuminance and high color temperature, as light source. Filter denoise, image enhancement and distortion correction are performed on video image to get a clear, distortionless and high resolution image where blood vessels and tissue morphology of uterine are displayed in real time. The medical electronic endoscope can offer doctors an effective means and reliable bases to early diagnose uterine diseases, especially early-stage malignant tumors.
Hysteroscopy prior to the first IVF cycle: A systematic review and meta-analysis
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Hysteroscopy not only provides accurate visual assessment of the uterine cavity, but also provides a chance to treat any pathology detected during the examination. The availability of hysteroscopes with smaller diameter has made the use of outpatient or office hysteroscopy feasible as a routine examination (De Placido et al., 2007). Currently, there is evidence that performing hysteroscopy before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles (Bosteels et al., 2010; El-Toukhy et al., 2008).
This systematic review and meta-analysis investigated the use of routine hysteroscopy prior to starting the first IVF cycle on treatment outcome in asymptomatic women. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, National Research Register and ISI Conference Proceedings. The main outcome measures were clinical pregnancy and live birth rates achieved in the index IVF cycle. One randomized and five non-randomized controlled studies including a total of 3179 participants were included comparing hysteroscopy with no intervention in the cycle preceding the first IVF cycle. There was a significantly higher clinical pregnancy rate (relative risk, RR, 1.44, 95% CI 1.08–1.92, P = 0.01) and LBR (RR 1.30, 95% CI 1.00–1.67, P = 0.05) in the subsequent IVF cycle in the hysteroscopy group. The number needed to treat after hysteroscopy to achieve one additional clinical pregnancy was 10 (95% CI 7–14) and live birth was 11 (95% CI 7–16). Hysteroscopy in asymptomatic woman prior to their first IVF cycle could improve treatment outcome when performed just before commencing the IVF cycle. Robust and high-quality randomized trials to confirm this finding are warranted.
Currently, there is evidence that performing hysteroscopy (camera examination of the womb cavity) before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles. However, recommendations regarding the efficacy of routine use of hysteroscopy prior to starting the first IVF treatment cycle are lacking. We reviewed systematically the trials related to the impact of hysteroscopy prior to starting the first IVF cycle on treatment outcomes of pregnancy rate and live birth rate in asymptomatic women. Literature searches were conducted in all major database and all randomized and non-randomized controlled trials were included in our study (up to March 2013). The main outcome measures were the clinical pregnancy rate and live birth rate. The secondary outcome measure was the procedure related complication rate. A total of 3179 women, of which 1277 had hysteroscopy and 1902 did not have a hysteroscopy prior to first IVF treatment, were included in six controlled studies. Hysteroscopy in asymptomatic woman prior to their first IVF cycle was found to be associated with improved chance of achieving a pregnancy and live birth when performed just before commencing the IVF cycle. The procedure was safe. Larger studies are still required to confirm our findings.
Hysteroscopic findings in infertile women: A retrospective study
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In spite of this, the place of routine hysteroscopy in management of infertile women with or without diagnosis of intrauterine pathology is debatable. This is because of invasive nature of hysteroscopy and the controversy about the real impacts of these disorders on fertility (21). However, this study confirms the importance of diagnostic office hysteroscopy in infertile patients either with abnormal or even normal hysterographic and ultrasonographic findings.
Lower pregnancy rates are observed in patients with uterine cavity anomalies. The correction of these anomalies has been associated with improved pregnancy rates. Diagnostic hysteroscopy can be performed in an office with minimal discomfort and superior sensitivity and specificity in evaluation of the uterine cavity. Our study was done to evaluate the importance of office hysteroscopy (OH) in diagnosis of pathology among infertile women.
To study incidence of abnormal hysteroscopic findings among infertile women.
We retrospectively studied 432 office hysteroscopies in patients referred to our unit because of their infertility problem. Two hundred and seventy-four patients (63.43%) were with primary infertility and 158 (36.57%) were with secondary infertility.
Normal hysteroscopic findings were reported in 344 women (79.63%). The other 88 (20.37%) were with abnormal hysteroscopy. The most common reported hysteroscopic abnormality was intrauterine adhesions (IUA) 31.81% (28/88) followed by endometrial polyp 26.13% (23/88). Pre-hysteroscopic uterine investigations (ultrasound or hysterography) were available, only, in 207 women. In 143 patients with normal pre-hysteroscopic uterine investigations, office hysteroscopy revealed uterine cavity abnormalities in 21 women (14.68%). Of those with abnormal pre-hysteroscopic findings, 64 patients, hysteroscopy examinations were normal in 16 patients (25%).
Office hysteroscopy should be a part of routine work up in infertile patients as routine uterine investigatory methods (ultrasonography and hysterography) have only sensitivity and specificity value of 67.19% and 85.31% respectively.
Endometrial polyps in infertile patients: Do high concentrations of interferon-gamma play a role?
2011, Fertility and Sterility
To assess levels of interferon-gamma (IFN-γ) both in serum and in endometrial biopsy samples from infertile patients with endometrial polyps, to investigate the molecular background involved in the formation of endometrial polyps and its potential role in infertility.
Prospective controlled trial.
Academic infertility clinic.
Twenty-one infertile women affected by endometrial polyposis represented the study group, and 21 homogeneous women without endometrial polyps were enrolled as control subjects.
Blood and endometrial biopsy collection from infertile women with and without endometrial polyps.
IFN-γ–positive cells were analyzed and counted as spot-forming colonies.
IFN-γ levels were significantly higher both in serum and in tissue biopsies of women with endometrial polyps.
High concentrations of IFN-γ were detected in infertile patients with endometrial polyps. The possible role of an inflammatory factor in a proliferative pathology represents a novel insight into the understanding of endometrial polyposis and its relationship with infertility.
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Citation Excerpt :
The SHG yielded better results: sensitivity, specificity, PPV, and NPV were 98%, 94%, 95%, and 98%, respectively. Hysteroscopy is considered the “gold standard” investigation for assessment of the uterine cavity, with the ability to treat uterine pathology in infertile patients, especially with repeated ART failures (2, 6, 9–29). According to our results, abnormal hysteroscopic findings were observed in 48 women (33.1%), in whom endometrial polyp, submucous myoma, and intrauterine adhesions were the most common.
To evaluate the importance of subjecting the patient to an outpatient (office) hysteroscopy (OH) before assisted reproductive techniques (ART) and patient compliance, possible side effects, and complications of the procedure.
Comparative observational cross-sectional study.
University hospital.
One hundred fifty-two patients attending the outpatient infertility clinic for pre-ART (IVF/intracytoplasmic sperm injection [ICSI]-ET) investigations, with normal uterine findings on hysterosalpingography (HSG).
Transvaginal sonography (TVS) and OH (using a rigid, 30-degree, 4-mm hysteroscope) by the vaginoscopic “no touch” technique.
Diagnostic value and compliance of OH.
The procedure was successful in 145 patients (95.4%); 51 of them (35.2%) had previous ART failures. Abnormal hysteroscopic findings were observed in 48 women (33.1%), in which endometrial polyp, submucous myoma, and intrauterine adhesions were the most common findings. The TVS was specific (100%) but not sensitive (41.7%) compared with OH. Abnormal hysteroscopic findings were significantly higher in patients with previous ART failure(s). The procedure was acceptable in almost all patients with no reported complications.
The OH should be part of the infertility workup before ART even in patients with normal HSG and/or TVS. This is especially relevant in cases with prior failed ART cycles.

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Compliance and diagnostic efficacy of mini-hysteroscopy versus traditional hysteroscopy in infertility investigation

Abstract

Objective

Study design

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Fertil Steril

Obstet Gynecol Clin North Am

J Am Assoc Gynecol Laparosc

Fertil Steril

J Am Assoc Gynecol Laparosc

Reprod Biomed Online

J Am Assoc Gynecol Laparosc

Fertil Steril

Am J Obstet Gynecol

J Obstet Gynaecol Can

Fertil Steril

Fertil Steril

Eur J Obstet Gynecol Reprod Biol

Obstet Gynecol

Fertil Steril