Fertility-Enhancing Hysteroscopic Surgery

 

 Buy Article Permissions and Reprints

ABSTRACT

Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyomata, intrauterine adhesions, and chronic endometritis, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. The position of hysteroscopy in current fertility practice is under debate. Although there are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women. However, in patients with at least two failed cycles of assisted reproductive technology, diagnostic hysteroscopy and, if necessary, operative hysteroscopy is mandatory to improve reproductive outcome. Office hysteroscopy is a powerful tool for the diagnosis and treatment of intrauterine benign pathologies. It is a simple, safe, reproducible, effective, quick, well-tolerated, and low-cost surgical procedure, with no need for an operating room.

REFERENCES

• 1 Royal College of Obstetricians and Gynaecologists Evidence-based Clinical Guidelines .Guideline: Fertility Assessment and Treatment for People with Fertility Problems, 2004. Available at: http://www.rcog.org.uk Accessed July 17, 2009
  Google Scholar
• 2 Crosignani P G, Rubin B L. The ESHRE Capri Workshop Group . Optimal use of infertility diagnostic tests and treatments.  Hum Reprod. 2000;  15 (3) 723-732
  CrossrefPubMedGoogle Scholar
• 3 Taylor E, Gomel V. The uterus and fertility.  Fertil Steril. 2008;  89 (1) 1-16
  CrossrefPubMedGoogle Scholar
• 4 Féghali J, Bakar J, Mayenga J M et al. Systematic hysteroscopy prior to in vitro fertilization.  [in French] Gynecol Obstet Fertil. 2003;  31 (2) 127-131
  CrossrefPubMedGoogle Scholar
• 5 Valle R F. Hysteroscopy in the evaluation of female infertility.  Am J Obstet Gynecol. 1980;  137 (4) 425-431
  PubMedGoogle Scholar
• 6 Kirsop R, Porter R, Torode H, Smith D, Saunders D. The role of hysteroscopy in patients having failed IVF/GIFT transfer cycles.  Aust N Z J Obstet Gynaecol. 1991;  31 (3) 263-264
  CrossrefPubMedGoogle Scholar
• 7 Varasteh N N, Neuwirth R S, Levin B, Keltz M D. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women.  Obstet Gynecol. 1999;  94 (2) 168-171
  CrossrefPubMedGoogle Scholar
• 8 Golan A, Eilat E, Ron-El R, Herman A, Soffer Y, Bukovsky I. Hysteroscopy is superior to hysterosalpingography in infertility investigation.  Acta Obstet Gynecol Scand. 1996;  75 (7) 654-656
  CrossrefPubMedGoogle Scholar
• 9 Wang C W, Lee C L, Lai Y M, Tsai C C, Chang M Y, Soong Y K. Comparison of hysterosalpingography and hysteroscopy in female infertility.  J Am Assoc Gynecol Laparosc. 1996;  3 (4) 581-584
  CrossrefPubMedGoogle Scholar
• 10 Cunha-Filho J SL, de Souza C AB, Salazar C C, Facin A C, Freitas F M, Passos E P. Accuracy of hysterosalpingography and hysteroscopy for diagnosis of intrauterine lesions in infertile patients in an assisted fertilization programme.  Gynaecol Endosc. 2001;  10 45-48
  CrossrefPubMedGoogle Scholar
• 11 Rama Raju G A, Shashi Kumari G, Krishna K M, Prakash G J, Madan K. Assessment of uterine cavity by hysteroscopy in assisted reproduction programme and its influence on pregnancy outcome.  Arch Gynecol Obstet. 2006;  274 (3) 160-164
  CrossrefPubMedGoogle Scholar
• 12 Bettocchi S, Ceci O, Di Venere R et al. Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. bipolar electrode.  Hum Reprod. 2002;  17 (9) 2435-2438
  CrossrefPubMedGoogle Scholar
• 13 Bettocchi S, Ceci O, Nappi L et al. Operative office hysteroscopy without anesthesia: analysis of 4863 cases performed with mechanical instruments.  J Am Assoc Gynecol Laparosc. 2004;  11 (1) 59-61
  CrossrefPubMedGoogle Scholar
• 14 Lorusso F, Ceci O, Bettocchi S et al. Office hysteroscopy in an in vitro fertilization program.  Gynecol Endocrinol. 2008;  24 (8) 465-469
  CrossrefPubMedGoogle Scholar
• 15 de Sá Rosa e de Silva A C, Rosa e Silva J C, Cândido dos Reis F J, Nogueira A A, Ferriani R A. Routine office hysteroscopy in the investigation of infertile couples before assisted reproduction.  J Reprod Med. 2005;  50 (7) 501-506
  PubMedGoogle Scholar
• 16 de Vries L D, Dijkhuizen F P, Mol B W, Brölmann H A, Moret E, Heintz A P. Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding.  J Clin Ultrasound. 2000;  28 (5) 217-223
  CrossrefPubMedGoogle Scholar
• 17 De Sutter P. Rational diagnosis and treatment in infertility.  Best Pract Res Clin Obstet Gynaecol. 2006;  20 (5) 647-664
  CrossrefPubMedGoogle Scholar
• 18 Richlin S S, Ramachandran S, Shanti A, Murphy A A, Parthasarathy S. Glycodelin levels in uterine flushings and in plasma of patients with leiomyomas and polyps: implications for implantation.  Hum Reprod. 2002;  17 (10) 2742-2747
  CrossrefPubMedGoogle Scholar
• 19 Kim M R, Kim Y A, Jo M Y, Hwang K J, Ryu H S. High frequency of endometrial polyps in endometriosis.  J Am Assoc Gynecol Laparosc. 2003;  10 (1) 46-48
  CrossrefPubMedGoogle Scholar
• 20 Valli E, Zupi E, Marconi D et al. Hysteroscopic findings in 344 women with recurrent spontaneous abortion.  J Am Assoc Gynecol Laparosc. 2001;  8 (3) 398-401
  CrossrefPubMedGoogle Scholar
• 21 Guimarães Filho H A, Mattar R, Pires C R, Araujo Júnior E, Moron A F, Nardozza L M. Comparison of hysterosalpingography, hysterosonography and hysteroscopy in evaluation of the uterine cavity in patients with recurrent pregnancy losses.  Arch Gynecol Obstet. 2006;  274 (5) 284-288
  CrossrefPubMedGoogle Scholar
• 22 Soares S R, Barbosa dos Reis M M, Camargos A F. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases.  Fertil Steril. 2000;  73 (2) 406-411
  CrossrefPubMedGoogle Scholar
• 23 Preutthipan S, Linasmita V. A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility.  J Obstet Gynaecol Res. 2003;  29 (1) 33-37
  CrossrefPubMedGoogle Scholar
• 24 Brown S E, Coddington C C, Schnorr J, Toner J P, Gibbons W, Oehninger S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study.  Fertil Steril. 2000;  74 (5) 1029-1034
  CrossrefPubMedGoogle Scholar
• 25 Pérez-Medina T, Bajo-Arenas J, Salazar F et al. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: a prospective, randomized study.  Hum Reprod. 2005;  20 (6) 1632-1635
  CrossrefPubMedGoogle Scholar
• 26 Annan H, Amoah C. Successful pregnancy after recurrent hysteroscopic polypectomy.  Gynecol Surg. 2006;  3 144-145
  CrossrefPubMedGoogle Scholar
• 27 Yanaihara A, Yorimitsu T, Motoyama H, Iwasaki S, Kawamura T. Location of endometrial polyp and pregnancy rate in infertility patients.  Fertil Steril. 2008;  90 (1) 180-182
  CrossrefPubMedGoogle Scholar
• 28 Bosteels J, Weyers S, Puttemans P et al. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review.  Hum Reprod Update. 2010;  16 (1) 1-11
  CrossrefPubMedGoogle Scholar
• 29 Donnez J, Jadoul P. What are the implications of myomas on fertility? A need for a debate?.  Hum Reprod. 2002;  17 (6) 1424-1430
  CrossrefPubMedGoogle Scholar
• 30 Oliveira F G, Abdelmassih V G, Diamond M P et al. Small uterine fibroids did not negatively affect the success of infertility treatment with intracytoplasmic sperm injection.  Evidence-based Obstet Gynecol. 2005;  7 31-32
  PubMedGoogle Scholar
• 31 Casini M L, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility.  Gynecol Endocrinol. 2006;  22 (2) 106-109
  CrossrefPubMedGoogle Scholar
• 32 Narayan R, Rajat, Goswamy K. Treatment of submucous fibroids, and outcome of assisted conception.  J Am Assoc Gynecol Laparosc. 1994;  1 (4 Pt 1) 307-311
  CrossrefPubMedGoogle Scholar
• 33 Farhi J, Ashkenazi J, Feldberg D, Dicker D, Orvieto R, Ben Rafael Z. Effect of uterine leiomyomata on the results of in-vitro fertilization treatment.  Hum Reprod. 1995;  10 (10) 2576-2578
  PubMedGoogle Scholar
• 34 Bernard G, Darai E, Poncelet C, Benifla J L, Madelenat P. Fertility after hysteroscopic myomectomy: effect of intramural myomas associated.  Eur J Obstet Gynecol Reprod Biol. 2000;  88 (1) 85-90
  CrossrefPubMedGoogle Scholar
• 35 Fernandez H, Sefrioui O, Virelizier C, Gervaise A, Gomel V, Frydman R. Hysteroscopic resection of submucosal myomas in patients with infertility.  Hum Reprod. 2001;  16 (7) 1489-1492
  CrossrefPubMedGoogle Scholar
• 36 Garcia C R, Tureck R W. Submucosal leiomyomas and infertility.  Fertil Steril. 1984;  42 (1) 16-19
  PubMedGoogle Scholar
• 37 Goldenberg M, Sivan E, Sharabi Z, Bider D, Rabinovici J, Seidman D S. Outcome of hysteroscopic resection of submucous myomas for infertility.  Fertil Steril. 1995;  64 (4) 714-716
  PubMedGoogle Scholar
• 38 Hart R, Khalaf Y, Yeong C T, Seed P, Taylor A, Braude P. A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception.  Hum Reprod. 2001;  16 (11) 2411-2417
  PubMedGoogle Scholar
• 39 Oliveira F G, Abdelmassih V G, Diamond M P, Dozortsev D, Melo N R, Abdelmassih R. Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection.  Fertil Steril. 2004;  81 (3) 582-587
  CrossrefPubMedGoogle Scholar
• 40 Dietterich C, Check J H, Choe J K, Nazari A, Fox F. The presence of small uterine fibroids not distorting the endometrial cavity does not adversely affect conception outcome following embryo transfer in older recipients.  Clin Exp Obstet Gynecol. 2000;  27 (3-4) 168-170
  PubMedGoogle Scholar
• 41 Jun S H, Ginsburg E S, Racowsky C, Wise L A, Hornstein M D. Uterine leiomyomas and their effect on in vitro fertilization outcome: a retrospective study.  J Assist Reprod Genet. 2001;  18 (3) 139-143
  CrossrefPubMedGoogle Scholar
• 42 Surrey E S, Lietz A K, Schoolcraft W B. Impact of intramural leiomyomata in patients with a normal endometrial cavity on in vitro fertilization-embryo transfer cycle outcome.  Fertil Steril. 2001;  75 (2) 405-410
  CrossrefPubMedGoogle Scholar
• 43 Yarali H, Bukulmez O. The effect of intramural and subserous uterine fibroids on implantation and clinical pregnancy rates in patients having intracytoplasmic sperm injection.  Arch Gynecol Obstet. 2002;  266 (1) 30-33
  CrossrefPubMedGoogle Scholar
• 44 Wang W, Check J H. Effect of corporal fibroids on outcome following embryo transfer in donor-oocyte recipients.  Clin Exp Obstet Gynecol. 2004;  31 (4) 263-264
  PubMedGoogle Scholar
• 45 Klatsky P C, Lane D E, Ryan I P, Fujimoto V Y. The effect of fibroids without cavity involvement on ART outcomes independent of ovarian age.  Hum Reprod. 2007;  22 (2) 521-526
  CrossrefPubMedGoogle Scholar
• 46 Vimercati A, Scioscia M, Lorusso F et al. Do uterine fibroids affect IVF outcomes?.  Reprod Biomed Online. 2007;  15 (6) 686-691
  CrossrefPubMedGoogle Scholar
• 47 Emanuel M H, Wamsteker K. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas.  J Minim Invasive Gynecol. 2005;  12 (1) 62-66
  PubMedGoogle Scholar
• 48 Bettocchi S, Siristatidis C, Pontrelli G et al. The destiny of myomas: should we treat small submucous myomas in women of reproductive age?.  Fertil Steril. 2008;  90 (4) 905-910
  CrossrefPubMedGoogle Scholar
• 49 Shokeir T A. Hysteroscopic management in submucous fibroids to improve fertility.  Arch Gynecol Obstet. 2005;  273 (1) 50-54
  CrossrefPubMedGoogle Scholar
• 50 Bettocchi S, Di Spiezio Sardo A, Ceci O et al. A new hysteroscopic technique for the preparation of partially intramural myomas in office setting (OPPIuM technique): a pilot study.  J Minim Invasive Gynecol. 2009;  16 (6) 748-754
  CrossrefPubMedGoogle Scholar
• 51 Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital Müllerian anomalies.  Hum Reprod. 1997;  12 (10) 2277-2281
  CrossrefPubMedGoogle Scholar
• 52 Reuter K L, Daly D C, Cohen S M. Septate versus bicornuate uteri: errors in imaging diagnosis.  Radiology. 1989;  172 (3) 749-752
  PubMedGoogle Scholar
• 53 Pellerito J S, McCarthy S M, Doyle M B, Glickman M G, DeCherney A H. Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography, and hysterosalpingography.  Radiology. 1992;  183 (3) 795-800
  CrossrefPubMedGoogle Scholar
• 54 Braun P, Grau F V, Pons R M, Enguix D P. Is hysterosalpingography able to diagnose all uterine malformations correctly? A retrospective study.  Eur J Radiol. 2005;  53 (2) 274-279
  PubMedGoogle Scholar
• 55 Wu M H, Hsu C C, Huang K E. Detection of congenital müllerian duct anomalies using three-dimensional ultrasound.  J Clin Ultrasound. 1997;  25 (9) 487-492
  CrossrefPubMedGoogle Scholar
• 56 Alborzi S, Dehbashi S, Parsanezhad M E. Differential diagnosis of septate and bicornuate uterus by sonohysterography eliminates the need for laparoscopy.  Fertil Steril. 2002;  78 (1) 176-178
  CrossrefPubMedGoogle Scholar
• 57 Fischetti S G, Politi G, Lomeo E, Garozzo G. Magnetic resonance in the evaluation of Mullerian duct anomalies.  [in Italian] Radiol Med (Torino). 1995;  89 (1–2) 105-111
  PubMedGoogle Scholar
• 58 Letterie G S, Haggerty M, Lindee G. A comparison of pelvic ultrasound and magnetic resonance imaging as diagnostic studies for müllerian tract abnormalities.  Int J Fertil Menopausal Stud. 1995;  40 (1) 34-38
  PubMedGoogle Scholar
• 59 Fedele L, Arcaini L, Parazzini F, Vercellini P, Di Nola G. Reproductive prognosis after hysteroscopic metroplasty in 102 women: life-table analysis.  Fertil Steril. 1993;  59 (4) 768-772
  PubMedGoogle Scholar
• 60 Pabuçcu R, Gomel V. Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility.  Fertil Steril. 2004;  81 (6) 1675-1678
  CrossrefPubMedGoogle Scholar
• 61 Homer H A, Li T C, Cooke I D. The septate uterus: a review of management and reproductive outcome.  Fertil Steril. 2000;  73 (1) 1-14
  CrossrefPubMedGoogle Scholar
• 62 Fedele L, Bianchi S, Agnoli B, Tozzi L, Vignali M. Urinary tract anomalies associated with unicornuate uterus.  J Urol. 1996;  155 (3) 847-848
  CrossrefPubMedGoogle Scholar
• 63 Nawroth F, Rahimi G, Nawroth C, Foth D, Ludwig M, Schmidt T. Is there an association between septate uterus and endometriosis?.  Hum Reprod. 2006;  21 (2) 542-544
  PubMedGoogle Scholar
• 64 Fayez J A. Comparison between abdominal and hysteroscopic metroplasty.  Obstet Gynecol. 1986;  68 (3) 399-403
  PubMedGoogle Scholar
• 65 Heinonen P K. Reproductive performance of women with uterine anomalies after abdominal or hysteroscopic metroplasty or no surgical treatment.  J Am Assoc Gynecol Laparosc. 1997;  4 (3) 311-317
  CrossrefPubMedGoogle Scholar
• 66 Lavergne N, Aristizabal J, Zarka V, Erny R, Hedon B. Uterine anomalies and in vitro fertilization: what are the results?.  Eur J Obstet Gynecol Reprod Biol. 1996;  68 (1–2) 29-34
  CrossrefPubMedGoogle Scholar
• 67 Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L, Vicino M. Office hysteroscopic metroplasty: three “diagnostic criteria” to differentiate between septate and bicornuate uteri.  J Minim Invasive Gynecol. 2007;  14 (3) 324-328
  CrossrefPubMedGoogle Scholar
• 68 Asherman J G. Traumatic intra-uterine adhesions.  J Obstet Gynaecol Br Emp. 1950;  57 (6) 892-896
  CrossrefPubMedGoogle Scholar
• 69 Bukulmez O, Yarali H, Gurgan T. Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis.  Hum Reprod. 1999;  14 (8) 1960-1961
  CrossrefPubMedGoogle Scholar
• 70 Tur-Kaspa I, Gal M, Hartman M, Hartman J, Hartman A. A prospective evaluation of uterine abnormalities by saline infusion sonohysterography in 1,009 women with infertility or abnormal uterine bleeding.  Fertil Steril. 2006;  86 (6) 1731-1735
  CrossrefPubMedGoogle Scholar
• 71 Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictive value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility.  Fertil Steril. 2000;  73 (2) 412-417
  CrossrefPubMedGoogle Scholar
• 72 Hinckley M D, Milki A A. 1000 office-based hysteroscopies prior to in vitro fertilization: feasibility and findings.  JSLS. 2004;  8 (2) 103-107
  PubMedGoogle Scholar
• 73 Ventolini G, Zhang M, Gruber J. Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population.  Surg Endosc. 2004;  18 (12) 1782-1784
  CrossrefPubMedGoogle Scholar
• 74 Weiss A, Shalev E, Romano S. Hysteroscopy may be justified after two miscarriages.  Hum Reprod. 2005;  20 (9) 2628-2631
  CrossrefPubMedGoogle Scholar
• 75 Schenker J G, Margalioth E J. Intrauterine adhesions: an updated appraisal.  Fertil Steril. 1982;  37 (5) 593-610
  CrossrefPubMedGoogle Scholar
• 76 Fernandez H, Al-Najjar F, Chauveaud-Lambling A, Frydman R, Gervaise A. Fertility after treatment of Asherman's syndrome stage 3 and 4.  J Minim Invasive Gynecol. 2006;  13 (5) 398-402
  CrossrefPubMedGoogle Scholar
• 77 Valle R F, Sciarra J J. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome.  Am J Obstet Gynecol. 1988;  158 (6 Pt 1) 1459-1470
  CrossrefPubMedGoogle Scholar
• 78 Di Spiezio Sardo A, Sorrentino F, Bramante S, Nappi L, Nappi C, Bettocchi S. Anatomical impediments at office hysteroscopy:”tip and tricks” for getting over them.  J Minim Invasive Gynecol. 2009;  16 (Suppl 36) S36
  PubMedGoogle Scholar

Stefano BettocchiM.D. 

Department Obstetrics, Gynecology, and Neonatology

University of Bari, Italy

Email: stefanoendo@tin.it