1. Chairperson: Haryana Chapter Of ISAR ,2011-2015
Executive member ISAR 2016-2017
Associate RCOG
Director: LOOMBA HOSPITAL AND IVF CENTRE ,
Ambala Cantt. HARYANA since 1988
Ex consultant at central hospital ,Arar,
Saudi Arabia
Ex senior resident Ganga Ram Hospital
New Delhi.
Graduate from GOMCO ,Patiala.1985.
Awards: President’s gold medal at university level.
Affiliations: ASRM,RCOG,FOGSI,ISAR,ACOG,,IAGE,
ASPIRE,Foetal Medicine Foundation
regular attendee at many national
and international conferences.
Achievements: First IVF/ART centre in haryana in 2003
Trained at CLEVELAND CLINIC U.S.A in
IVF/ICSI
Trained at HARVARD in advanced
ultrasound in fetal medicine
Advanced laparoscopy training at Kiel,
Germany.
Specialised : Infertility/ART, Fertility related
Fields Laparoscopic surgeries, Fetal medicine
Recurrent pregnancy loss
www.loombahospital.
com
Dr.Poonam Loomba
M.D.
loombapoonam
@gmail.com
www.loombaivf.com

2. Role of hysteroscopy and laparoscopy
in IVF
Poonam Loomba ,M.D.
Loomba hospital and IVF Centre
Ambala Cantt.

4. Kurt Semm (1927-2003)
As one of the most critically
acclaimed fathers of
laparoscopy.
 In 1970, after becoming the
chairman of Ob/Gyn at the
University of Kiel, his co-workers
demanded that he undergo a
brain scan because, they said,
“only a person with brain damage
would perform laparoscopic
surgery”
German Engineer and Gynecologist.
Introduced automatic insufflator,
thermocoagulation ,loop knots,
irrigation device in 1983, performed
endoscopic appendectomy as part of
A gynecologic procedure.

5. Learning objectives
• Utilising the effective tool of hysteroscopy and
selecting appropriately, patients for operative
laparoscopy prior to IVF with an evidence
based approach.
• Make changes in clinical practice as per
expertise and available resources by
introducing MAST in infertility management.

6. Success of IVF depends upon
Implantation which further depends
upon synchronization of factors:
• Quality of embryos
• Optimal culture conditions
• Receptivity of the endometrium
• Maternal immune system

7. Three important components of management

9. Background Check
• Majority of pelvic pathology in infertile women is frequently not well
appreciated by routine examinations and the usual diagnostic procedures
• Tubal morphology , patency, ovarian morphology, endometriosis, adnexal
adhesions can all be resolved with Laparoscopy which is the gold
standard .
• Endometrial polyps, submucous fibroids, uterine septum, or intrauterine
adhesions can be found in 10% to 15% of women seeking treatment for
subfertility and can be confirmed with hysteroscopy.
• Removal of polyps improves pregnancy rates to 63% vs 28% with biopsy
• Removal of sub mucous myomas improves preg rates to 39% vs 21% with
expectant management

10. Tools to evaluate female pelvic organs
• Hysterosalpingography
• TVUS/3D/4D Technology
• Saline infusion sono hysterography
• Hysteroscopy
• MRI
Hysteroscopy, however, is considered the gold standard for
diagnosis of intrauterine lesions

11. HSG
• Defines cavity and fallopian tubes thus can diagnose
developmental /acquired uterine anomalies as well as tubal
pathologies.
• Cost effective.
• HSG has relatively low sensitivity (50%) and positive predictive
value (PPV; 30%) for diagnosis of endometrial polyps and
submucous myomas.
• Can not differentiate between septate and bicornuate uterus
• Low radiation,Painful ,Less patient compliance

12. TVUS /3D 4D
• TVUS has low sensitivity and specificity for detecting intra
cavitary lesions.
• 3D/4D imaging can diagnose developmental anomalies of
uterus.
• Non invasive.
• Needs expertise and equipment
• Learning curve

13. Saline infusion sonohysterography
More image than imagination
May be as effective as hysteroscopy in
detecting intra cavitary abnormalities
More cost effective and simple to perform

14. ASRM Practice guidelines
Hysteroscopy is the definitive method for the
diagnosis and treatment of intrauterine
pathology.
It is also the most 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

15. The inSIGHT study: costs and effects of routine hysteroscopy
prior to a first IVF treatment cycle. A randomised controlled trial
Smit JG ,Kasius JC et al 2012
• In (IVF) and (ICSI) treatment a large drop is present between embryo
transfer and occurrence of pregnancy.
• The implantation rate per embryo transferred is only 30%.
• Studies have shown that minor intrauterine abnormalities can be found in
11-45% of infertile women with a normal transvaginal sonography or
hysterosalpingography.
• Two randomised controlled trials have indicated that detection and
treatment of these abnormalities by office hysteroscopy after two failed
IVF cycles leads to a 9-13% increase in pregnancy rate.
• Therefore, screening of all infertile women for intracavitary pathology prior
to the start of IVF/ICSI is increasingly advocated.
• In absence of a scientific basis for such a policy, this study will assess the
effects and costs of screening for and treatment of unsuspected
intrauterine abnormalities by routine office hysteroscopy, with or without
saline infusion sonography (SIS), prior to a first IVF/ICSI cycle.

17. Septal resection

18. • Is surgical management of uterine
septum necessary prior to IVF?
Cutter
Keeper

19. Prevalence of septum
General Infertile RPL

20. HYSTEROSCOPIC METROPLASTY FOR SEPTATE
UTERUS A meta analysis of 16 published series Fertil
steril 2000 (Homer,Liand Cooke)
Before After
Pregnancy 1062 491
Miscarriage 933 (88%) 67 (14%)
Preterm delivery 95 (9%) 29 (6%)
Term delivery 34(3%) 395 (80%)

21. TRUST
The Randomised Uterine Septum
Transection Trial
2014......RCT finally published... Removal of
septum produced better outcome.
Dutch multicentered study .Septum length 1/4th
of cavity

22. Intra uterine synichae

23. AAGL Guidelines for Intra uterine Synichae
• Hysteroscopy is the method of choice for diagnosis.
• HSG and SISHG can be done in absence of hysteroscopy.
• MRI is not fully evaluated.
• 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.
• IUD is not advisable after resection.
• Foley’s catheter is not recommended.
• Estrogens can be used to prevent recurrence.
• Hyaluronic acid gel can reduce adhesions .
• Since recurrence rate is high :1 in 3 women, reassessment of
cavity after 2 to 3 cycles with HSG or Office hysteroscopy.

24. Submucous fibroids –grading :
to decide the route of surgery
• T0- whole in endometrial cavity
• T1 - >50% in endometrial cavity
• T2- < 50% in endometrial cavity

25. SISHG

26. • 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

27. SUB MUCOUS
HYSTEROSCOPIC
MYOMECTOMY
SUBSEROUS AND INTRAMURAL
<4CM
OBSERVE
4-7CM >7CM
LM/AM?

28. Sub-mucous myomas

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

30. 39 yr female sec infertility POR

31. 34 yr Pr Infertility .failed IUI Cycles

32. Polyps

33. For the infertile patient with a polyp, surgical
removal is recommended to allow natural
conception or assisted reproductive technology
a greater opportunity to be successful (Level A)
AAGL Guidelines

37. Hysteroscopic tubal catheterization in
infertility
Indications-
• Obstruction & occlusion of ostium & proximal
tract
• Transfer of gametes or embryos

38. Laparoscopy

39. Role of diagnostic laproscopy in
infertility
1. Tubal block on HSG
2. Suspected peri-tubular adhesions
3. Suspected endometriosis
4. Mullerian anomaly
5. Unexplained infertility

40. J Hum Reprod Sci. 2010 Jan;3(1):20-4.
Role of laparohysteroscopy in women with normal
pelvic imaging and failed ovulation stimulation with
intrauterine insemination.
Jayakrishnan K, Koshy AK, Raju R.
• CONCLUSION: One in four women had significant
pelvic pathology where treatment could possibly
improve future fertility. Diagnostic laparoscopy has a
role in infertile women with no obvious abnormality
before they proceed to more aggressive treatments.

41. Hydrosalpinges

42. Hydrosalpinx
Can be diag by
• TVS- sensitivity of 34%
• HSG –sensitivity of 65%
Hydrosalpinges visible on USG benefit most
from surg in terms of preg after IVF

43. Hydrosalpinx

44. Effect on IVF Success
• Numerous studies have shown that
hydrosalpinges have a detrimental effect on IVF
success rates.
• This finding may be due to mechanical flushing of
the embryos from the uterine cavity, decreased
endometrial receptivity, or a direct embryotoxic
effect Patients with hydrosalpinges visible on
ultrasound may be more significantly affected (33,
34).

45. Fertility and Sterility
Volume 90, Issue 5, Supplement , Pages S66-S68, November 2008
Salpingectomy for hydrosalpinx prior to in vitro
fertilization
Practice Committee of the American Society for Reproductive Medicine in
collaboration with The Society of Reproductive Surgeons
Summary and conclusions
1.The live birth rate achieved with IVF among women with hydrosalpinges is
approximately one half that observed in women without hydrosalpinges.
2.In women with hydrosalpinges, preliminary laparoscopic salpingectomy or
proximal tubal occlusion improves subsequent pregnancy and live birth rates
achieved with IVF. For every six women with hydrosalpinges, one more ongoing
pregnancy will be achieved if salpingectomy or tubal occlusion is performed
before IVF.
3.Data are insufficient to permit recommendations regarding the effectiveness
of alternative treatments such as laparoscopic neosalpingostomy, transvaginal
aspiration of hydrosalpingeal fluid, hysteroscopic tubal occlusion, or antibiotic
treatment.

46. Fertility and Sterility
Volume 95, Issue 8 , Pages 2474-2476, 30 June 2011
Effects of salpingectomy on ovarian response in
controlled ovarian hyperstimulation for in vitro
fertilization: a reappraisal
We conclude that salpingectomy does not influence
ovarian response in COH. However, it is important
to excise the hydrosalpinx close to the tube to
avoid compromising the blood supply to the ovary
and this could be achieved without a laparotomy
incision. Instead of using electrocautery, one can
use other modalities including an ultrasound
scalpel or scissors and ligature. Whether
hysteroscopy proximal tubal occlusion will improve
the IVF PR in women with hydrosalpinx remains to
be seen (9).

48. Endometriosis : ESHRE 2014
 It is found in 10%-15% of the general population and in up to
one third of the infertile population
 Gold standard to establish the diagnosis is histologic analysis
of tissue samples obtained at the time of surgery
 Ovarian endometriomas should be removed by cystectomy,
rather than drainage and coagulation, to avoid recurrence.
 Deep infiltrating endometriosis should be managed by
experienced surgeons, because complication rates are high.
 There is no proven benefit of hormonal treatment as adjuvant
therapy to surgery, but nor is there proven harm with this
approach. After cystectomy, hormonal therapy may be offered
to reduce the risk for recurrence

49. Medical therapy alone does not improve one’s chance of
achieving a pregnancy and should not be offered for this
reason.
 Surgical treatment of early-stage endometriosis improves
fertility outcome
For advanced stage surgery may be considered but most
of them require IVF .
 Suppression of endometriosis with a GnRH agonist or
extended OCP use improves IVF outcome.
ESHRE 2014

50. Endometrioma

51. Endometriotic Cysts
 Interfere with successful oocyte collecting during IVF
 May be associated with pain.
 They may increase the risk for adnexal torsion during pregnancy
 Surgery could negatively affect ovarian reserve ,thus not
recommended in POR
 The removal of larger endometriomas (> 3 cm) has not been shown
to improve IVF outcome, although surgery is recommended to those
with painful symptoms.