Author Name: Dr Swati Chaurasia || Mentor Name: DR Amol Lunkad on April 27, 2020
As we know that infertility means failure to achieve pregnancy after having timed and unprotected intercourse for one year. There are so many causes of infertility out of them one of the causeis uterus. Different methods are used to assess the uterine abnormalities.
HSGor Hysterosalpingogram (X-ray with dye): It is less accurate and just can roughly help in diagnosis.
Trans vaginal sonography: It is non invasive but not very sensitive and a fairly accurate tool for diagnosis especially in good hands.
Hysteroscopy: It allow direct visual assessment of cervical canal and uterine cavity to find out any pathology in the uterus. Hysteroscopy gives view of uterine cavity, endometrial lining, shape and volume of the endometrial cavity.
In hysteroscopy a telescope is passed through the cervix into the uterine cavity fitted with light source. No cuts are required. Fluid (Saline solution- Normal Saline 0.9%) or CO2 gas is used to expand the cavity to see the inner lining of uterus. Ideal time to do hysteroscopy is post menstrual that is day 4 to 9 of start of menstrual periods. It not only provide accurate diagnosis but also helpful in direct treatment of uterine pathologies under vision like :
1)Polyp – This is overgrowth of inner uterine layer called endometrium and it can causeInter menstrual bleeding or spotting, heavy bleeding, and infertility. Infertility due to mechanical interference with sperm and embryo transport, altering endometrial receptivity and impairment of embryo implantation.
Treatment is hysteroscopic removal of polyp.
2)Fibroids – These are non-cancerous tumor of the muscular wall of the uterus , fibroids may be subserosal, intramural, submucosal. Submucosal fibroids are located in the cavity of the uterus which distort the uterine cavity; even small lesions in this location may lead to bleeding and infertility.
Treatment: Subserosal and intramural are removed by laparoscopy and submucosal fibroid can be removed by hysteroscopy.
3)Uterine septum: It is a fibrous band which divide uterine cavity into two. Septum may be partial or complete. It is associated with high risk for infertility, miscarriage, premature birth.
Treatment: Hysteroscopictranscervical resection of the septum.
4)Uterine adhesions: These are scar tissues inside uterine cavity. This scarring can be mild with thin flimsy bands or more severe with formation of thick band. In the most severe cases, partial or total occlusion or destruction of the uterine cavity can occur. This may be due to previous surgery or infection of endometrium or any severe injury to the endometrium.
Treatment: Under hysteroscopic guidance cutting of scar tissue done by using micro scissors.
Also hysteroscopy is used for the cases with recurrent abortions or miscarriage and recurrent IVF failure to know the exact cause of such repeated events and also to treat them effectively.
Recurrent pregnancy loss means two or more spontaneous pregnancy losses before 20 weeks of gestation. Investigative methods for recurrent pregnancy loss includes parental karyotype, find out maternal endocrine problems, thrombophilia, anti-phospholipid antibodies, foetus karyotype and hysteroscopy. One of the important causes of recurrent pregnancy loss is Uterine abnormality which can be best diagnosed and treated effectively by doing hysteroscopy. Hysteroscopy is an important diagnostic and therapeutic tool to for intrauterine reasons of pregnancy loss like intrauterine adhesions, polyp, submucous fibroid, Mullerian abnormalities. That’s why woman after two abortions can be advise hysteroscopy that will reveal anomalies or pathologies and improve pregnancy outcome.
Eggs and sperm are taken and fertilised outside the body in a laboratory to produce embryo which is then transferred into the uterus by the infertility specialist. This transferred embryo should get attached to the inner lining of the uterus (endometrium) and start growing (Implantation)and develop into a successful pregnancy. The most important success determining step of IVF is Implantation which in turn depends on endometrium and its receptivity.
There is no role of routine diagnostic hysteroscopy for evaluation of uterine cavity before IVF ineach and every case. With the advent of very good trans-vaginal sonography (TVS) and sono-salphigography it is not warranted to do diagnostic hysteroscopy in all IVF patients, only in those patients with abnormal findings on trans-vaginal sonography or abnormal sono-salphingogram can be treated with therapeutic hysteroscopy.
In IVF among all the difficulties faced, Recurrent implantation failure (RIF) is the most challenging.
Recurrent Implantation failures means three times failure of good quality embryo to implant onto the uterine wall during IVF treatment. Implantation failure may be due to embryonic factor or uterine factor. The quality of embryo can be accessed microscopically and with the help of preimplantation genetic screening, but it’s difficult to evaluate uterine receptivity. Minor pathologies if missed on sonography(TVS) which can be the cause of IVF failure can be diagnosed and treated on hysteroscopy.That’s why it is important to find out intrauterine reasons which can lead to implantation failure such as inflammation, adhesions, undiagnosed polyps and treat them.
Hysteroscopy is a good diagnosticand therapeutic tool in IVF. In case of recurrent implantation failure and recurrent abortions it is helpful in correction of pathologies and thus improving pregnancy outcome and would be helpful in saving the cost of patient who are undergoing repeated IVF cycle, where failure occur due to missed pathologies.
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