Office hysteroscopy and infertility ..alaa hassanin

4.  Hysteroscopy is the process of viewing
and operating in the endometrial cavity
from a transcervical approach.
 It can be:
• Diagnostic
• operative

6.  1869:--Pantaleon visualize polypoidal
tumor in uterus.
 1925:--Rubin used cysto-urethro-scope
to look into uterus.
o He used water to distend Uterus and
to wash lense.
o He also used carbon dioxide

7.  1971:--Lindeman used CO2 with a
pressure from 50 to 100 cc/minute.
by using Hysteroflator which is a special
instrument for using Co2 as distending
media.

8.  1960-70:--low viscosity fluids like saline or
ringer lactate, with pressure of 50 to 100
mm Hg, is popularly used in diagnostic
hysteroscopy.
• Fluid bottle is suspended
high over a stand.
• Advantages: cheap & easily
available.

9.  1971:--Menken used high viscosity fluid
(HYSCON)
• It is 30% Dextran in 10% glucose

10. 1981:--Hamou renewed the field of
hysteroscopy with new, improved visual
optics and instruments of fine diameter
((4 mm))
1980s and 90s :-- Hysteroscopy have
been further popularized by:
• Simpler techniques.

11. • ability to perform the examination in an
ambulatory setting as an outpatient
procedure in the outpatient clinic without
anaesthesia or cervical dilatation.
• Moreover, it offers direct visualization and
enables clinicians to diagnose and treat
intrauterine pathology during the same
session.

12.  Direct visualization of any pathology
 No X-ray exposure
 Insertion under visualization decreases
chance of perforation

14.  Look into endo-cervix
 Look into uterine cavity
 Look at endometrium
 Look at tubal ostium

15. Indications Of Hysteroscopy
IN
Infertility
Abnormal uterine bleeding
Repeated abortions
Diagnosis and follow-up of
endometrial hyperplasia
Investigation of
intrauterine pathologies
suspected in other exams
Tubal catheterization &
sterilization
TO
 Locate submucous
myoma.
 Diagnose uterine
septum.
 Locate & remove lost
I.U.C.D.
 Locate endometrial
polyp
 Locate uterine synechae
 Identify foreign bodies

16. EQUIPMENTS

18. Telescope Sheath
lens barrel eyepiece

19. INSTRUMENTS REQUIRED FOR HYSTEROSCOPY

20. Flexible (3-5 mm)
Advantages.
accommodate the irregularly shaped
uterus.
for diagnostic and operative procedures.
accommodates to the cervix more easily
than does a rigid scope.
Minimal risk of trauma
Disadvantages. Greater cost & inability to widen
view or to magnify the image

21. Rigid (4 mm or more):
most frequently used in the operating room
with intravenous (IV) sedation or general
anesthesia
Advantages.
wide range of diameters allows for in-office
and complex operating-room procedures.
 The 4-mm scope:
offers the sharpest and clearest view
accommodates surgical instruments.
requires minimal cervical dilation.

22. Disadvantages
 larger than 5 mm in diameter require
increased cervical dilation.
 more pain than those in the flexible group
Microhysteroscope (2.4-2.7 mm)
 New generation of small diameter
hysteroscopes.
 With atraumatic insertion techniques allows
very high success rates for diagnostic
hysteroscopy

23. Newer diagnostic models:
 may lack the sheath
 Outer sheaths have accessory channels that
enable the inflow and outflow of the
distention media
 Outer sheaths
have also ports to
insert operative &
manipulating
instruments

25. The intrauterine cavity is a potential
space so hysteroscopic examination
requires the cavity be distended with
either gas or liquid

26. Electrolyte
Low
viscosity
fluids
High
viscosity
fluids
Non-
electrolyte
Dextran
70CO2

27.  Flow rates 100mL/min. , pressure100 mmHg,
By using Hysteroflator (Low flow, low flow
insufflators).
 Advantages:
Low cost, visibility good if no bleeding.
 Disadvantages:
Requires Hysteroflator

28. Low viscosity fluids
Electrolyte-containing solutions:
 Normal saline and lactated Ringer’s solution.
 Gives the possibility to easily ‘find and treat
in situ’ many of the lesions observed without
the need to change media.

29. Nonelectrolyte solutions:
 1.5% glycine, 3% sorbitol, 5% mannitol, and 5%
dextrose.
 mannitol is the safest of all non-electrolyte solutions
 Advantages:
 compatible with monopolar energy systems.
 Disadvantages:
 Risk of hyponatremia if absorbed in large volumes.
 Glycine contraindicated in significant hepatic
dysfunction.
 Sorbitol should be avoided in patients with impaired
glucose tolerance.

30. High viscosity fluids
Dextran 70 (Hyscon):
 Advantages:
 Excellent light transmission so visibility excellent
even with bleeding.
 Simplicity of use.
 Does not escape easily through the fallopian tubes
or cervix  so maintains uterine distension.
 Does not mix with blood.

31.  Disadvantages:
 Expensive
 crystallize when it dries
 Allergic reactions
 Very thick and messy, difficult to infuse it through
the hysteroscope
 Fluid overload
 (DIC) disseminated intravascular coagulopathy

32. CO2 Fluid medium
Risk of dissemination Very low Slightly higher
Picture Very clear Clear
Diagnosis of bleeding disorders Limited Very good
Comparison of fluid and CO2 distention media

33. Normal saline should be used as it offer
advantages (shorter and less discomfort )
over CO2 instillation
New Zealand Guidelines Group

34. It is preferable to perform hysteroscopy in the
proliferative phase or immediately following a
menstrual period.

35.  Conventional panoramic hysteroscopy requires some
form of anesthesia
 smaller caliber flexible hysteroscopes require little to
no anesthesia

36. Active PID
Active profuse uterine bleeding
Recent uterine perforation
Pregnancy
Cervical Cancer.
Cardiovascular or systemic diseases

37. Complications may occur due to
Instrumental procedure
Distension media.
Inadequate visualization
Anesthetic agent

38. Complications:
Uterine perforation
Hemorrhage
Infection: Because of excellent drainage, the
risk for infection with office hysteroscopy is
very low.
Pain: which is the most common reason for
failure
Gaseous intravasation: occurs only at CO2
pressures above 400 mm Hg.

39. Other Complications:
Hypervolemia
Hyponatremic encephalopathy
cardiac asystole & arrhythmia.
Hypercarbia & acidosis.
Vasovagal syndrome: Risk is higher with the
use of a rigid hysteroscope and CO2.

41.  Office hysteroscopes can be successfully used in an
office setting for gynecologic indications without
general anaesthesia in an ambulatory setting with low
cost & minimal morbidity and high patient acceptance.
 It is one of the safest and most easily acquired
surgical skills in gynecology.
 The outpatient hysteroscopy failure rate is less than
half (2%) with the mini-hysteroscope compared with
the traditional 5 mm hysteroscope (5%).

43.  Sterile gloves are mandatory, and any
instruments inserted into the uterus must be
sterile.

44. Vaginal misoprostol prior to diagnostic
hysteroscopyreduces cervical resistance
facilitates the procedure so  reduces
complication
(Fong & Sing, Evidence-based Obs. &Gyn. 2001)

45.  No cervical dilatation
 No speculum - no tenaculum
 No blind insertion of the instruments into the
uterine cavity
 Sight-controlled insertion of the hysteroscope
 Use non-irritating distension media (saline)
 No anaesthesia or analgesia necessary

47.  Infertility is failure to achieve a pregnancy within
one year of regular unprotected intercourse.
 Uterine factors represent 10-15% of the causes 
include congenital anomalies, intrauterine
adhesions, infection, leiomyomas and polyps.
 Hysteroscopy is becoming an important tool in the
evaluation of infertility in women, it is the preferred
procedure for the diagnosis of uterine pathology in
infertile patients. (Wong et al., 2000)

48.  Studies have shown successful rates of 98%
to l00% by office hysteroscopy.
 Hysteroscopic examination has been proven
to have superior sensitivity and specificity in
evaluating the endometrial cavity over
hysterography

49. Hysteroscopy is only recommended by the
WHO when clinical or complementary exams
((ultrasound, HSG)) suggest intrauterine
abnormality, or after (IVF) failure.
(Rosa et al., 2005)
However many specialists feel that
hysteroscopy is a more accurate tool because
of the high false positive and false negative
rates of intra uterine abnormality with HSG.

50. The goal of using hysteroscopy is:
 To identify structural abnormalities such as
polyps, myomas, or uterine septum.
 To obtain a sample of the endometrium

51. INDICATIONS
 Abnormal HSG.
 Abnormal uterine bleeding
 Suspected intrauterine pathology (polyps,
submucous leiomyomas, uterine septa,
intrauterine adhesions)
 Uterine anomalies
 Unexplained infertility
 Planned intrauterine surgery
 misplaced or embedded foreign bodies
 Tubal cannulation
(Rafael, 2008)

54.  This study included 30 women all presenting
with infertility. They all underwent office
hysteroscopy in the outpatient clinic at Kasr
AL Iny hospital.
 Of these, 22 women were diagnosed with
primary infertility and 8 with secondary
infertility.
 The following has been done to every
participant in this study:
History taking
General and local
examination.
Semen analysis for husband
Hormonal assay
U/S
HSG
Office hysteroscopy

55. Hysteroscopy revealed:
Normal uterine cavity in 12 patients (40%),
of these:
 10 patients (33.3%) with primary infertility
and
 2 patients (6.7%) with secondary infertility.

56. 18 (60%) patients had abnormal hysteroscopic
findings, of these:
 12 (40%) with primary infertility and
 6 (20%) with secondary infertility.
Among women with abnormal results, 3
patients (10%) showed more than one
abnormality.

57. Normal
findings
percent
Abnormal
findings
percent
Primary infertility 10 33.3% 12 40%
Secondary
infertility
2 6.7% 6 20%
total 12 40% 18 60%
Intrauterine findings according to type of infertility

58. Hysteroscopic Finding Number Percent
Polyps 13 43.3%
Intra-uterine adhesions 3 10%
Myoma 2 6.7%
Intrauterine anomalies (Intra-uterine septum) 1 3.3%
Endometrial hypertrophy 2 6.7%
0
2
4
6
8
10
12
14
abnormalfindings
Polyp
Intra-uterineadhesions
Myoma
Intra-uterineseptum
Endometrial hypertrophy

59. Intrauterine abnormalities according to type of
infertility
Type of
infertility
Polyp Intrautrine
synechia
Myoma Intrauterine
anomalies (septum)
Endometrial
hypertrophy
Primary
infertility
10 2 2 0 1
Secondary
infertility
3 1 0 1 1
Total 13 3 2 1 2

60. Normal uterine cavity Normal endocervical mucosa

61. Normal tubal ostium Normal tubal ostium

62. Multiple Intrauterine polypTwo intrauterine polyps

63. Intrauterine polyptwo Intrauterine polyp

64. Submucous fibroid Submucous fibroid

65. Submucous fibroidCornual polyp

66. Intrauterine adhesions Intrauterine band of adhesions

67. Intrauterine septum

68.  (Malhotra and Sood, 1997) Made a study similar to our
current study in the number of patients and in the results.
19 pt. (60%)
13 pt. (40%) abnormal uterine findigs
normal uterine findings
18 pt. (60%)
12 pt. (40%)
Normal & Abnormal uterine findings in our study
Abnormal uterine findigs
Normal uterine findings

69.  A study done by (Aletebi, 2010), In a group of 43
women, hysteroscopy done and (19) women (44%)
had normal hysteroscopic findings. And (24) women
(56%) presented structural uterine abnormalities
these results are near to presented results in our
study
56%
44%
Abnormal findigs
Normal findigs

70.  Another larger study done on 1000 infertile patients
scheduled for IVF underwent office hysteroscopy, (38%) of
patients had abnormal intrauterine hysteroscopic findings
the commonest finding was endometrial polyps (32%), the
second common finding was intrauterine adhesions (3%),
and submucous fibroids (3%), then end. Hypertrophy and
uterine septum.
0%
5%
10%
15%
20%
25%
30%
35%
Polyp Intra-uterine
adhesions
Myoma Endometrial
hypertrophy
Intra-uterine
septum
Hysteroscopic findings

71. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
polyps intrauterine
adhesions
Myoma Endometrial
hypertrophy
intrauterine
septum
Hysteroscopic findings in our study
 These results are also similar to the entire findings in
our study in which the most common finding was
endometrial polyps followed by intrauterine
adhesions, and submucous myoma, then endometrial
Hypertrophy & uterine septum and other findings

73.  Hysteroscopic diagnosis and treatment has
become very important in patients with infertility.
It is one of the safest and most easily acquired
surgical skills in gynecology.
 Office hysteroscopy is an outpatient procedure
that does not require anaesthesia and has better
patient compliance and thus constitutes a
definitive diagnostic test.
 Hysteroscopy is useful in identifying endometrial
abnormalities not detectable on HSG, it is more
accurate than HSG because of the false positive
and false negative rates associated with HSG.

74.  Our study was designed to investigate the role of
office hysteroscopy in determining the uterine
cavity abnormalities in infertile patients attending
outpatient clinic.
 The study revealed presence of intrauterine polyps,
submucous fibroids, intrauterine adhesions,
Müllerian anomalies (intrauterine septum). These
lesions can be treated during hysteroscopy and
their treatment may lead to successful conception