What Is Hysteroscopy? Steps, Types, Procedure & Role in IVF

Introduction

If you have been trying to conceive for some time, or if your IVF cycles have failed despite good quality embryos, you may still be missing an important answer. What is really happening inside your uterus?

Fertility investigations mostly look at the uterus from the outside. For instance, ultrasounds, blood tests and even laparoscopy examine the surrounding structures such as the ovaries, the fallopian tubes and the pelvic cavity. However, the inside of the uterus, which is where an embryo needs to implant and grow, often remains uninspected until something goes noticeably wrong.

This is where hysteroscopy helps. It is a simple procedure that lets your doctor look directly inside the uterus through a small camera. There are no cuts or stitches, but just a real-time view of the uterine cavity. In most cases, the doctor can also fix what is found on the same day.

It is more important than many people realise. Research shows that uterine abnormalities are found in 18 to 50% of women with repeated IVF failures and most of these are only visible through hysteroscopy. Conditions such as uterine polyps, scar tissue from past infections or procedures, and uterine tuberculosis are frequently encountered in Indian fertility clinics. These conditions can prevent pregnancy without causing any obvious symptoms.

However, despite this, many women have never heard of hysteroscopy or feel hesitant about it, which is completely understandable. Still, the more you know about this procedure, the less daunting it appears.

This guide covers everything about hysteroscopy, including what a hysteroscopy is, why doctors recommend it, what happens during the procedure, what it costs and how quickly you can recover and move ahead with your fertility treatment.

What Is a Hysteroscopy?

Hysteroscopy is a minimally invasive medical procedure in which a gynaecologist inserts a thin, lighted instrument called a hysteroscope through the vagina and cervix into the uterus. It is done without making any cuts in the abdomen. The tip of the hysteroscope is fitted with a small camera, which sends magnified, high-definition images of the uterine cavity onto a monitor in real time.

This allows the surgeon to inspect the uterine lining (endometrium), the opening of the fallopian tubes and the shape and structure of the uterine cavity with high precision.

For diagnostic procedures, the hysteroscope is typically 3-5 millimetres in diameter. However, it is slightly wider for operative procedures, which require additional instruments to be passed alongside the camera.

Hysteroscopy can be purely diagnostic or operative. In several cases, what begins as a diagnostic hysteroscopy may become an operative one if a polyp, fibroid or adhesion is discovered and immediately removed.

What Is the Hysteroscope and How Does It Work?

A hysteroscope is a thin, lighted tube with a camera attached to it, which is passed through the cervix to visualise and treat the inside of the uterus.

Modern hysteroscopes used in fertility hospitals are rigid, high-definition instruments that are connected to a light source, a fluid delivery system and a camera unit. The camera projects magnified images onto a monitor.

During the procedure, the surgeon slowly advances the hysteroscope through the opening of the cervix. The uterine cavity is then inflated with a clear fluid to separate the walls and get a clear view. Surgical tools are passed through additional instrument channels alongside the camera for simultaneous treatment.

Why Is Hysteroscopy Recommended?

Hysteroscopy is generally recommended if a specialist suspects that an abnormality inside the uterine cavity is causing infertility, implantation failure or recurrent miscarriage. It is also recommended when a routine investigation identifies a finding that requires further assessment.

Why Would a Fertility Specialist Recommend Hysteroscopy Before IVF?

Generally, fertility specialists recommend hysteroscopy before IVF to rule out or treat uterine cavity abnormalities, which may reduce the chance of embryo implantation.

If the uterine cavity is not in optimal condition, implantation may fail even if high-quality embryos are transferred during IVF. For example, a small uterine polyp, a thin band of scar tissue or a small septum (none of these are generally visible on a standard ultrasound) may dramatically reduce the chances of successful implantation.

Research shows that hysteroscopy and correction of uterine abnormalities before IVF can significantly improve clinical pregnancy rates compared to IVF without prior hysteroscopy.

What Conditions Can Hysteroscopy Diagnose and Treat?

Hysteroscopy can diagnose and treat various conditions such as uterine polyps, fibroids, intrauterine adhesions (Asherman's syndrome), uterine septum and abnormal uterine bleeding.

Uterine Polyps (Endometrial Polyps)

Endometrial polyps are soft, fleshy outgrowths from the uterine lining. They are commonly discovered during hysteroscopy, particularly in women experiencing irregular bleeding or recurrent implantation failure. Polyps can interfere with embryo implantation. They disrupt the endometrial environment and trigger a localised inflammatory response. However, hysteroscopic polypectomy (that involves removal of the polyp using a wire loop), which is a straightforward process, is shown to improve IVF outcomes. According to studies, polyp removal before IVF may double the clinical pregnancy rate compared to leaving polyps in place.

Intrauterine Adhesions (Asherman's Syndrome)

Intrauterine adhesions are bands of scar tissue. They form as a result of injury to the endometrium, most commonly following dilation and curettage (D&C) procedures after miscarriage or abortion, uterine infection or uterine tuberculosis. Hysteroscopic adhesiolysis, which involves careful cutting and removal of adhesions under direct vision, may restore the uterine cavity. It can also dramatically improve the prospects of a successful pregnancy.

Uterine Septum

A uterine septum is a congenital abnormality in which a septum (band of fibrous tissue) divides the uterine cavity partially or completely. It is a common structural uterine anomaly, which is strongly associated with recurrent miscarriage. As the septum has a poor blood supply, an embryo that implants on it is unlikely to survive. Hysteroscopic metroplasty, which involves the surgical removal of the septum, can be performed with great precision, minimal risk and a short recovery. It is also associated with significantly improved pregnancy outcomes.

Submucosal Fibroids

Submucosal fibroids are fibroids that project into the uterine cavity. These can be most disruptive to fertility. Apart from distorting the cavity, they impair endometrial blood flow and create a hostile environment for implantation. However, fibroids that are entirely or predominantly within the cavity can be removed hysteroscopically.

Uterine Tuberculosis

Genital tuberculosis is a major cause of infertility in India. It most commonly affects the uterine lining and the fallopian tubes. TB of the endometrium may cause severe scarring and destruction of the endometrial glands. This results in a thin, poorly receptive endometrium, which cannot support implantation. Hysteroscopy allows direct visualisation of the cavity and biopsy of the endometrium. It provides a definitive diagnosis that is not always possible by other means.

Abnormal Uterine Bleeding

Hysteroscopy is also used to investigate abnormal uterine bleeding, including heavy periods, irregular bleeding, or postmenopausal bleeding, by visualising the endometrial lining directly and taking targeted biopsies. Identifying and treating the cause of abnormal uterine bleeding can be a vital step toward improving endometrial receptivity before IVF.

How Is Hysteroscopy Performed?

The whole experience can feel much less daunting if you know what to expect. Here is a simple walkthrough of everything that happens from your pre-operative instructions to going home.

How Should You Prepare for a Hysteroscopy?

Preparation for your hysteroscopy involves timing the procedure appropriately in your menstrual cycle. Fasting may be required if general anaesthesia is planned. You should follow your surgeon’s specific instructions.

While your gynaecologist will provide you personalised instructions, general preparation mainly includes the following:

• Timing: Most commonly, hysteroscopy is performed in the first half of the menstrual cycle after the period has ended but before the ovulation. The endometrium is thin during this period and the cavity is easiest to visualise.
• Fasting: You will need to fast for 6 to 8 hours beforehand if general anaesthesia or deep sedation is planned.
• Cervical preparation: In the case of women with a narrow cervical canal, the surgeon may prescribe misoprostol tablets the night before to gently soften and dilate the cervix.
• Medications: Let your doctor know about all medications and supplements, including iron tablets, blood thinners and any herbal remedies.
• Companion: A family member or companion should accompany you and take you home. This is especially important when sedation or general anaesthesia is used.

What Happens During the Hysteroscopy Procedure?

The hysteroscopy procedure involves positioning, cervical dilation, insertion of the hysteroscope, cavity inspection, treatment and removal of the instrument. It is typically completed in 10 to 45 minutes.

Here is what happens during each step in the procedure:

• Positioning: You are positioned on an examination table with your legs supported.
• Anaesthesia: Depending on the type of hysteroscopy and your hospital, you may be given local anaesthesia, sedation or general anaesthesia.
• Speculum insertion: A speculum is inserted into the vagina to expose the cervix.
• Cervical dilation: The cervical opening is gently dilated if required to allow passage of the hysteroscope.
• Hysteroscope insertion: The hysteroscope is advanced through the cervix into the uterine cavity.
• Fluid distension: Saline or another distension medium is gently introduced to expand the cavity and get a clear view.
• Inspection: The surgeon examines the entire uterine cavity, including the walls, fundus, ostia and endometrial lining.
• Treatment (if required): If a polyp, fibroid, adhesion or septum is found, it may be removed or treated.
• Completion: Once the procedure is complete, the hysteroscope is gently withdrawn. No sutures are needed.

While a diagnostic hysteroscopy generally takes 10 to 20 minutes, operative hysteroscopy may take 20 to 45 minutes, depending on the complexity of findings and treatment.

Is Hysteroscopy Painful?

In most cases, women experience mild to moderate pain during and after the procedure. However, pain is generally well-managed and short-lived.

The level of pain can vary depending on the type of anaesthesia used, whether cervix dilation is required and individual pain tolerance.

What Are the Benefits of Hysteroscopy?

Hysteroscopy has several clear advantages over other diagnostic methods used to examine the uterus.

Hysteroscopy offers direct, real-time visualisation of the uterine cavity that is not possible with ultrasound, MRI or HSG.

For example, there are multiple investigations that can be used to assess the uterus, such as transvaginal ultrasound (TVS), saline infusion sonography (SIS), hysterosalpingography (HSG) and MRI. While these can suggest abnormalities, they cannot confirm or treat them.

Hysteroscopy is the only investigation that offers:

• Direct visualisation: The surgeon can see the uterine lining exactly as it is.
• Targeted biopsy: It is possible to take tissue samples from specific abnormal areas.
• Immediate treatment: Polyps, fibroids, adhesions and septa can be treated in the same session.
• No abdominal incisions: There are no cuts or no external scarring.
• Short recovery: In most cases, women can return to normal activity within 24 to 48 hours.
• Day care procedure: In the vast majority of cases, the entire procedure is performed and completed in a single hospital visit.

How Does Hysteroscopy Improve IVF Success Rates?

Hysteroscopy identifies and corrects uterine abnormalities that might otherwise prevent embryo implantation. Thus, it improves IVF success rates.

Hysteroscopy can be transformative for women undergoing IVF, particularly for those who have a history of failed cycles.

• According to research, performing hysteroscopy before IVF in women with a normal ultrasound can lead to increased live birth rates.
• In women with recurrent implantation failure, correcting uterine abnormalities (identified through hysteroscopy) can significantly improve subsequent IVF pregnancy rates.
• Removing endometrial polyps before IVF can double the clinical pregnancy rate.
• Hysteroscopically treating intrauterine adhesions can restore cavity anatomy and improve implantation prospects.

Apart from its direct impact on implantation, hysteroscopy offers fertility specialists crucial information about endometrial health, cavity shape and the presence of TB. All this information can be crucial for personalised IVF treatment planning.

What Is the Cost of Hysteroscopy in India?

Cost is one of the most important considerations for patients in India. However, it can vary based on several factors. In India, hysteroscopy typically costs between INR 15,000 and INR 70,000, depending on its type and the hospital. Diagnostic hysteroscopy costs less compared to operative hysteroscopy.

The average cost of diagnostic hysteroscopy may range between INR 15,000 and INR 30,000. On the other hand, the average cost of operative hysteroscopy may lie between INR 30,000 and INR 55,000.

Cost can also vary between metro cities and tier 2 cities, and between corporate multispecialty hospitals and standalone gynaecology clinics.

However, several major health insurers in India now cover hysteroscopy when deemed medically necessary. You should check if your health policy covers gynaecological day-care procedures and obtain pre-authorisation if required.

What Factors Affect the Cost of Hysteroscopy in India?

Several factors affect the cost of hysteroscopy in India, including city, hospital type, procedure complexity, anaesthesia, surgeon’s experience and whether biopsy or additional treatment is performed.

• City: Cost in metro cities like Mumbai, Delhi and Bengaluru can be 20 to 40% higher than in smaller cities.
• Hospital type: Corporate hospitals may charge significantly more compared to nursing homes or fertility clinics.
• Procedure scope: Diagnostic hysteroscopy is less expensive compared to operative hysteroscopy.
• Anaesthesia: General anaesthesia increases the total cost compared to local anaesthesia or sedation.
• Surgeon’s experience: Senior reproductive surgeons or hysteroscopy specialists charge higher fees.
• Biopsy and histopathology: Separate laboratory charges may be incurred for TB culture, PCR and endometrial biopsy.

It is important to get a written cost estimate before proceeding.

What to Expect During Recovery from Hysteroscopy?

The recovery period is short for most women and mainly depends on whether the procedure was diagnostic or operative.

How Long Does Recovery from Hysteroscopy Take?

Generally, women recover fully from diagnostic hysteroscopy within 24 to 48 hours. However, in the case of operative hysteroscopy, they may need 3 to 7 days before resuming normal activity.

One of the most significant advantages of hysteroscopy is faster recovery, particularly if you compare it to open uterine surgery or even laparoscopy.

Here is what to expect during recovery:

What Should You Avoid After Hysteroscopy?

You must avoid sexual intercourse, tampons, swimming, and strenuous exercise for at least 1 to 2 weeks after hysteroscopy to let the uterine lining heal.

Your surgeon may provide you with specific post-procedure instructions. However, the general guidelines include:

• Avoid sexual intercourse for 1 to 2 weeks or until bleeding completely stops.
• Use sanitary pads only until healing is complete. No tampons or menstrual cups.
• Avoid swimming or immersion baths for at least 1 to 2 weeks.
• Do not engage in strenuous exercise until cleared by your surgeon.
• Light spotting or watery discharge for up to 2 weeks is normal and expected.
• Take prescribed antibiotics if given, which will help reduce infection risk.

What Warning Signs After Hysteroscopy Require Immediate Medical Attention?

Urgent medical attention is required for high fever, heavy bleeding, severe abdominal pain, foul-smelling discharge or signs of infection at any site.

While hysteroscopy is a very safe procedure, complications can rarely occur. You should contact your doctor or go to the emergency department if you experience:

• Fever above 38°C (100.4°F)
• Heavy vaginal bleeding that soaks more than one pad per hour.
• Severe cramping or abdominal pain, which cannot be controlled by painkillers.
• Foul-smelling vaginal discharge can be a sign of infection.
• Dizziness, fainting or feeling very unwell.
• If periods do not return within 6 to 8 weeks of operative hysteroscopy, it can be a sign of re-adhesion.

The complication rate for diagnostic hysteroscopy is extremely low. However, it is slightly higher for operative hysteroscopy and includes uterine perforation, cervical laceration, fluid overload and post-operative infection. The risks are minimum when an experienced hysteroscopic surgeon performs the procedure at a well-equipped centre.

What Are Some Special Considerations for Women Related to Hysteroscopy and Fertility?

Here are some special considerations for women related to hysteroscopy and infertility.

Is Hysteroscopy Relevant for Women With Uterine Tuberculosis?

In India, where genital TB remains a significant cause of infertility, hysteroscopy is among the most significant tools to diagnose uterine tuberculosis.

Genital tuberculosis (TB) is far more prevalent in India compared to most other countries. It frequently affects uterine endometrium and fallopian tubes. Endometrial TB may lead to progressive destruction of the uterine lining, which results in a thin, scarred, poorly receptive endometrium. In severe cases, it can cause complete obliteration of the cavity.

Genital TB is often silent, which means it has no obvious symptoms and only comes to attention when a woman is diagnosed for infertility. Apart from allowing direct visualisation of the endometrium, hysteroscopy permits targeted biopsy. In case of women with a suspicious clinical history or positive TB serology, hysteroscopy with endometrial sampling is an important test.

It is also crucial to understand that natural pregnancy or IVF using one's own uterus may not be achievable in cases of severe uterine TB with destroyed endometrium. However, it can be determined accurately and compassionately through the use of hysteroscopy.

Does Hysteroscopy Improve Outcomes After Recurrent Implantation Failure?

Hysteroscopy is strongly recommended after recurrent implantation failure, as uterine abnormalities are found in up to half of these cases.

Recurrent implantation failure (RIF) means failure to achieve pregnancy after the transfer of three or more good-quality embryos. It is one of the most distressing experiences in fertility treatment. For women investing in repeated IVF cycles, it is critical to understand why implantation is failing.

Studies show that a significant percentage of women with RIF have a uterine cavity abnormality that could be identified through hysteroscopy, but was not detected on routine ultrasound.

International bodies also, including ESHRE recommend hysteroscopy as part of the investigation workup for RIF.

How Is Hysteroscopy Different From a D&C?

Hysteroscopy lets the surgeon see inside the uterus before acting. However, a D&C (dilation and curettage) is performed without direct visualisation.

Dilation and curettage (D&C) involves dilating the cervix. A curette is used to scrape the uterine lining. It is a common procedure used after miscarriage, for diagnostic purposes or to manage abnormal bleeding. However, in D&C, the surgeon cannot see the uterine cavity and has no visual guidance.

Hysteroscopy is basically superior to D&C and offers several advantages. It allows the surgeon to see exactly what is being treated, take targeted biopsies from specific areas, preserve healthy endometrium and avoid inadvertent damage. D&C itself is among the leading causes of intrauterine adhesions. This makes hysteroscopy a better alternative and sometimes a remedial procedure for damage caused by previous D&Cs.

How to Address Stigma and Delayed Diagnosis in India?

Internal gynaecological procedures and particularly the ones that involve vaginal access, are associated with discomfort or cultural stigma for Indian women. There are concerns about the procedure being perceived as invasive or inappropriate. Apart from it, there is a general reluctance to discuss uterine health openly. It means that hysteroscopy is often declined, delayed or not suggested.

This delay can have real consequences. For instance, a uterine polyp that could have been removed in 20 minutes under local anaesthesia may be the reason that 2 or 3 cycles have failed.

If you have been recommended hysteroscopy and are feeling hesitant, you must know this. The procedure is performed entirely internally, leaves no visible scars and is completed within an hour or less. Moreover, recovery happens in days and not weeks. There is only mild and temporary discomfort. The information obtained through hysteroscopy can change your entire fertility trajectory.

Conclusion

Hysteroscopy is among the most valuable and underutilised tools in fertility medicine. While it is the only procedure that allows the doctor to look directly inside the uterine cavity, it also allows them to correct what was found, often in the same appointment.

Hysteroscopy is particularly relevant for Indian women navigating the fertility journey. A thorough internal uterine assessment is essential due to the prevalence of uterine conditions such as endometrial polyps, intrauterine adhesions, uterine tuberculosis and submucosal fibroids. Based on research, treating uterine cavity abnormalities before IVF improves clinical pregnancy rates and live birth rates in subsequent cycles.

While the procedure is minimally invasive, it is widely available across India in metro and tier-2 cities. It is also relatively affordable and associated with a very short recovery time. Whether you are preparing for your first IVF cycle, investigating current implantation failure or trying to understand why natural conception could not happen, hysteroscopy can give you the answers and solutions that other investigations may not.

Do not let stigma or hesitation stop you. Just talk to your fertility specialist about whether hysteroscopy is the right next step for you.