Lecture delivered by Dr SUjoy Dasgupta at ISAR Bengal Conference 2017, where he was invited as the Faculty

1. Fertility Enhancing Hysteroscopic Surgery
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons) MS (Obst & Gynae- Gold Medalist) DNB FIAOG
Assistant Professor: SRIMSH, Durgapur
Consultant:
RSV Hospital, Kolkata
Techno India Hospital, Kolkata
Behala Balananda Brahmachary Hospital, Kolkata
Hindusthan Health Point Hospital, Kolkata
Secretary, Perinatology Committee: BOGS- 2016-17
Managing Committee Member: BOGS- 2016-17
15 Publications: National and International Journals

2. Infertility- a big enigma?

3. Endometrium- Friendly or Hostile?
• Uterine factors- Found in 2-3% of the couples struggling to conceive
• can be present in 10-15% cases of “unexplained subfertility”

4. Hysteroscopy
• Uterine Pathology in TVS
• Unexplained Subfertility
• Subfertility with Repeated Miscarriage
• IVF Failure

5. Operative Hysteroscopy Enhancing Fertility
• Polypectomy
• Myomectomy
• Adhesiolysis
• Septum Resection
• Tubal Canulation

6. Endometrial Polyp

7. Polyps and Infertility
• can distort the endometrial cavity
• may have a detrimental effect on endometrial receptivity
• Frequently associated with obesity, diabetes, PCOS
(hyperestrogenism)
• Infertile women are more likely to be diagnosed with an
endometrial polyp (Level B)*
*AAGL Practice Report
7

8. Management algorithm for polyps
Annan JJ, Aquilina J, Ball E. The management of endometrial polyps in the 21st century. The Obstetrician & Gynaecologist 2012;14:33–38.

9. Evidences
9
Bosteels J, et al. Cochrane
Database Syst Rev. 2015 Feb
21;(2):CD009461.
IUI the hysteroscopic removal of polyps prior to IUI
increases the odds of clinical pregnancy
P´erez-Medina T, et al. Hum
Reprod 2005;20:1632–5
IUI Hysteroscopic polypectomy increases pregnancy rate
Stamatellos I, et al. Arch
Gynecol Obstet. 2008
May;277(5):395-9.
IVF In women in whom the only reason for subfertility
was endometrial polyps, hysteroscopic polypectomy
improved the rate of spontaneous conception
regardless of size or number of polyps
Ben-Nagi J, et al.. Reprod
Biomed Online 2009;19:737–
44
IVF Polypectomy improves implantation rate

10. 10

11. AAGL Guideline
•Hysteroscopic Polypectomy is the Gold
Standard Treatment
•For the infertile patient with a polyp,
surgical removal is recommended to allow
natural conception or ART a greater
opportunity to be successful (Level A).

12. Making certain diagnosis
1. TVUS -investigation of choice where available (Level B).
2. The addition of color or power Doppler improves accuracy (Level B).
3. SIS and 3-D imaging improves the diagnostic capacity (Level B).
4. Blind D/C biopsy should not be used for diagnosis of endometrial
polyps (Level B).
AAGL Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

14. Fibroids

15. Fibroids and Subfertility
• Position
• Uterine receptivity
• Pressure Effect
• Blocking tubal ostia
• Cytokine production
• Poor implantation

16. Evidences
Pritts, et al. 2009 Meta-
analysis
Removal of submucous fibroids seems to confer
benefit in terms of pregnancy rates.
T. Shokeir, et al.
2010
RCT Women, with no other factors associated with
infertility, undergoing hysteroscopic myomectomy
had a better possibility of becoming pregnant.
Irrespective of fibroid size, number, and location
in both groups.

17. Classification
T0 whole in
endometrial
cavity
T1 >50% in
endometrial
cavity
T2 >50% in
myometrium

18. • Location of myomas
• Number of myomas
• Size of myomas
• Asymptomatic/symptomatic
• Associated adenomyosis/endometriosis
• Distortion of endometrium
• Previous failed IVF cycles
• Previous pregnancy losses
• Available expertise and resources
• Other factors affecting fertility
Before decision making

19. AAGL Practice guidelines for sub mucous myomas :Level A
• Removal improves fertility esp for type 0 and type 1 but remains low
as compared to normal uteri
• HSG is less sensitive and specific
• TVUS is less sensitive and specific than SIS/ Hysteroscopy/ MRI.
• MRI is superior in classification and realtionship of myomas with
serosa .
• Cervical preparation can reduce trauma .
• Pre op use of GnRHa corrects anaemia

21. Intrauterine Adhesion

22. Asherman’s Syndrome
• Hypeomenrrhoea/ Amenorrhoea
• Infertility
• Recurrent Implantation Failure
• Recurrent Pregnancy Loss
• Preterm Labour
• Fetal Growth Restriction
• Intra-uterine Fetal Demise
• Placenta Accreta

23. ASRM Scoring for Intrauterine Adhesion
Look at... Size/description Score
Extent of
cavity
involved
<1/3 1
1/3–2/3 2
>2/3 4
Type of
adhesions
Filmy 1
Filmy and dense 2
Dense 4
Menstrual
pattern
Normal 0
Hypomenorrhoea 2
Amenorrhoea 4
Prognostic classification
Stage I (mild) 1–4
Stage II (moderate) 5–8
Stage III (severe) 9–12

24. Prognosis
• Restoration of menstruation- 70-90%
• Pregnancy Rate- 60-90%
(20-40% for severe disease and with recurrence)
• Term Pregnancy- 40-80%
• Pregnancy Complications- High
• Recurrence Rate- 30%
Advanced reproductive Care Inc 2002

25. AAGL Guidelines for Intra-uterine Synichae
• Hysteroscopic guidance is the method of choice with any tool.
• Laparoscopy may be combined in cases of dense and lateral adhesions.
• Antibiotics not a routine practice.
• IUCD/ Foley’s catheter- not recommended.
• Estrogens can be used to prevent recurrence.
• Hyaluronic acid gel can reduce adhesions
• Reassessment of cavity after 2 to 3 cycles with HSG or office
hysteroscopy

27. Müllerian Anomalies

28. Uterine Anomalies
• spontaneous miscarriage –
Septate > Bicornuate
• recurrent pregnancy loss
• malpresentation
• Fetal growth restriction
• preterm labour
• dysmenorrhea
• Association with Subfertility
Cause-effect relationship- ?

29. Septum, Infertility and Miscarriage

30. Septum and RPL
• All women with RPL should be assessed for uterine anomaly
RCOG Green Top Guidelines No 17. April 2011. The Investigation and Treatment of Couples with Recurrent First trimester and
Second-trimester Miscarriage

31. Cutter vs Keeper

32. Hysteroscopic Metroplasty For Septate Uterus –
A Meta-analysis Of 16 Published Series
Before After
Pregnancy 1062 491
Miscarriage 933 (88%) 67 (14%)
Preterm Delivery 95 (9%) 29 (6%)
Term Delivery 34 (3%) 395 (80%)
Homer,Liand, Cooke. Fertil Steril 2000

33. More Evidences
Mollo et al. Fertil
Steril 2009
Prospective
Controlled Trial
women with unexplained
infertility
Hysteroscopic resection of the septum
improves the pregnancy rate and live
birth rate
Ozgur et al.
Reprod Biomed
Online 2004
Retrospective
Study
Before IVF Incomplete septum removal improves
pregnancy, live birth rate and lowers
risk of miscarriage
Ensieh Shahrokh
Tehraninejad. Int J
Fertil Steril. 2013
Retrospective
Analysis
Subfertility, RPL Hysteroscopic metroplasty improves live
birth rate in both groups
Dural O, et al. JSLS,
2013
Retrospective
Analysis
Subfertility with past H/O
miscarriage
Hysteroscopic metroplasty improves live
birth rate, irrespective of the method
used
Fedele L, et al.
Hum Reprod, 1996
Observational
Study
Hysteroscopic Metroplasty
with residual septum <1
cm
Does not adversely affect reproductive
outcome

34. Cochrane Review, 2017
• Most studies of metroplasty for a septate uterus combine women
with recurrent miscarriage and infertility, and no study has been
published that randomizes infertile women to treatment versus no
treatment. For this reason controversy exists as to whether infertile
women should undergo metroplasty
C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty versus expectant management for
women with recurrent miscarriage and a septate uterus,” Cochrane Database of Systematic Reviews
2017, Issue 1. Art. No.: CD008576

35. “Prophylactic” Metroplasty
• May not increase fecundability, but may improve live birth rate
• Can prevent miscarriage and obstetric complications in IVF-pregnancy
• To be considered before IVF, especially if no other infertility factors
were present

36. Hysteroscopic septal resection
40
• Principle- to horizontally divide rather
than excise the septum.
• Aim- fundal myometrium is no less than
1.5 cm in depth
• IUD insertion for 3 months with
estrogenisation is only recommended for
complete or wide septa

38. Proximal Tubal Block

39. Screening Tests
Sensitivity Specificity
HSG 53% 87%
HyCoSy 93% 89%
Papaioannou S, et al. Tubal evaluation in the investigation of subfertility: a structured comparison of tests. BJOG
2004;111:1313–21.
Papaioannou S, et al. Tubal assessment tests: still have not found what we are looking for. Reprod Biomed Online
2007;15:376–82.

40. Proximal Tubal Blockage (PTB)
• Accounts for approximately 15% of cases of tubal factor infertility
Salpingitis isthmica nodosa (SIN) 40%
Endometriosis
Cornual Polyp
}10%
Cornual Spasm 20%
Stromal Oedema
Tubal debris
Intraluminal adhesions
Viscid Secretion
}30%
• Suresh YN, Narvekar NN. TOG 2014;16:37–45.

41. Treatment of PTB
IVF vs Tubal Surgery
• Patient’s preferences
• Age
• Associated Fertility
Problems
• Cost, Expertise, Resources
• Risk of OHSS
Most of the
PTB
• Fluroscopic Selective
Salpingography
• Hysteroscopic Tubal
cannulation
SIN • tubal resection and
anastomosis of the diseased
inflammatory area- highest
success compared to tubal
catheterisation or expectant
management irrespective of
tubal patency
Suresh YN, Narvekar N. Role of surgery to optimise outcome of assisted conception treatments. The Obstetrician & Gynaecologist
2013;15 91–8.

42. Recommendations
• For women with proximal tubal
obstruction, selective
salpingography plus tubal
catheterisation, or hysteroscopic
tubal cannulation, may be
treatment options because
these treatments improve the
chance of pregnancy.
NICE Clinical guideline Fertility problems: assessment
and treatment

44. American Society for Reproductive Medicine (ASRM)
• Hysteroscopy is the definitive method for the diagnosis and
treatment of intrauterine pathology.
• Costly and invasive method for uterine cavity evaluation, it should be
reserved for further evaluation and treatment of abnormalities
defined by less invasive methods such as HSG and sonohysterography
Fertility and Sterility, vol. 98, no. 2, pp. 302–307, 2012
48

45. Routine Hysteroscopy before IVF?
INSIGHT Trial
• Routine hysteroscopy does not improve livebirth rates in infertile
women with a normal transvaginal ultrasound of the uterine cavity
scheduled for a first IVF treatment. Women with a normal
transvaginal ultrasound should not be offered routine hysteroscopy.
• Smit JG, et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised
controlled trial. Lancet. 2016 Jun 25;387(10038):2622-9.

47. Take Home Message
• Routine hysteroscopy before 1st IVF- ?
• Intrauterine Pathology- should be addressed by hysteroscopic diagnosis
and treatment
• Hysteroscopic surgery increases chance of pregnancy and live birth-
spontaneously/ after IUI/ IVF
• Vaginoscopic/ “No Touch” approach has several advantages
• Safe, cost-effective than conventional surgery

48. Bertrand Russel
Thank You