Frequency distribution of pregnancy occurrence in infertile women after diagnostic-surgical hysteroscopy

Abstract

Background: Mullerian disorders are present in 5-25% of infertile women. Myoma, polyp and endometrial adhesions are among other involved factors in infertility.Objective: The aim of this study was to determine the frequency distribution of pregnancy occurrence in infertile women after the diagnostic-surgical hysteroscopy on selected infertile cases including those with abnormal uterine. Materials and Methods: One hundred and fifteen women with at least 12 months infertility who had abnormal uterine cavity and patients who had at least 4 unsuccessful ART cycles with no confirmed diagnosis of uterine cavity problem, underwent diagnostic hysteroscopy and if required hysteroscopic surgery. Follow up sonography and HSG performed 2-3 months later and all subjects were followed for pregnancy occurrence for 12 months. Results: Mean age of subjects was 32.65 ± 6.2 years and mean of infertility duration was 8.33 ± 5.25 years. Based on the sonography and HSG performed prior to the hysteroscopy, respectively 69.6% and 41.8% of the subjects had abnormality. In 65.2% of the cases, hysteroscopy showed septum, myoma, endometrial adhesion and irregularity and all of them underwent hysteroscopic operation. Among the operated cases, in 27 cases pregnancy occurred during the first 6 postoperative months and in 2 cases during the second 6 postoperative months of whom one case was EP.Conclusion: There was no significant difference in the rate of pregnancy occurrence between those who had abnormal hysteroscopy and those who were normal (p= 0.63). This can show the variation of infertility causes and the fact that infertility is not just due to uterine problems. Therefore, the repetition

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Iranian Journal of Reproductive Medicine Vol.5. No.3. pp:99-102, Summer 2007

Frequency distribution of pregnancy occurrence in
infertile women after diagnostic-surgical hysteroscopy

Ensieh Shahrokh Tehrani Nejad1 M.D., Tayebeh Naderi2 M.D., Shohreh Irani3 M.D.,Elham Azimi
Nekoo1 M.D.

1 Department of Obstetric and Gynecology, Tehran University of Medical Sciences and Royan Institute,
Tehran, Iran.
2 Department of Obstetric and Gynecology, Kerman University of Medical Sciences, Kerman, Iran.
3 Royan Institute, Tehran, Iran.

Received: 11 December 2006; accepted: 23 July 2007

Abstract
Background: Mullerian disorders are present in 5-25% of infertile women. Myoma,
polyp and endometrial adhesions are among other involved factors in infertility.
Objective: The aim of this study was to determine the frequency distribution of
pregnancy occurrence in infertile women after the diagnostic-surgical hysteroscopy on
selected infertile cases including those with abnormal uterine.
Materials and Methods: One hundred and fifteen women with at least 12 months
infertility who had abnormal uterine cavity and patients who had at least 4 unsuccessful
ART cycles with no confirmed diagnosis of uterine cavity problem, underwent
diagnostic hysteroscopy and if required hysteroscopic surgery. Follow up sonography
and HSG performed 2-3 months later and all subjects were followed for pregnancy
occurrence for 12 months.
Results: Mean age of subjects was 32.65 ± 6.2 years and mean of infertility duration
was 8.33 ± 5.25 years. Based on the sonography and HSG performed prior to the
hysteroscopy, respectively 69.6% and 41.8% of the subjects had abnormality. In 65.2%
of the cases, hysteroscopy showed septum, myoma, endometrial adhesion and
irregularity and all of them underwent hysteroscopic operation. Among the operated
cases, in 27 cases pregnancy occurred during the first 6 postoperative months and in 2
cases during the second 6 postoperative months of whom one case was EP.
Conclusion: There was no significant difference in the rate of pregnancy occurrence
between those who had abnormal hysteroscopy and those who were normal (p= 0.63).
This can show the variation of infertility causes and the fact that infertility is not just
due to uterine problems. Therefore, the repetition of therapeutic measures and longer
follow up of infertile cases are necessary.

Key Words: Infertility, Hysteroscopy, Uterine cavity problem.

Introduction

Mullerian anomalies are present in 3-5% of the
general population and in 5-25% of the women
with recurrent abortion, late abortion and preterm
labor. Uterine septum, the most common anomaly
that is present in 2-3% of the general population is

Correspondence Author:
Dr Ensieh Shahrokh Tehrani Nejad, Tehran University of
Medical Sciences and Royan Infertility Institute,
Tehran, Iran.
E-mail: Tehraninejad@royaninstitute.org
associated
prognosisincluding
complications (1). Liomyoma, the most common
solid pelvic tumor in women, is seen in 20-25% of
the women over 35 years and accounts for 10% of
the pregnancy complications (1, 2). Endometrial
polyps, endometrial adhesions following infections
and tuberculosis and iatrogenic adhesions are some
other disorders leading to infertility and abortion
increase. In 1973, hysteroscope was used for the
first time for intrauterine adhesions lysis and after
that it has been used for various purposes including
with unfavorable
infertility
productivity
pregnancy and

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Shahrokh Tehrani Nejad et al
Iranian Journal of Reproductive Medicine Vol.5. No.3. Summer 2007
100
myomectomy. Hysteroscopy is indicated in
selected infertile cases including those with
abnormal hystrography, infertility with unknown
cause and recurrent
Hysteroscopy can be used as a diagnostic and
correction method in patients with anatomical
anomalies that have been suspected or proved by
hystrosalpingography (HSG) or sonography (2).
Since 10-15% of the infertility causes are uterine
factors (2), a main part of reproductive problems
can be solved by using hysteroscopy.
Improvement in productivity after polypectomy
has been reported in several studies (3-12). The
rate of pregnancy
hysteromyomectomy has been reported to be equal
to that after laparatomy and transabdominal
myomectomy, but it is less invasive with more end
organ saving (13). Therefore, due to the
complications of open surgeries, myomectomy
with hysteroscope has been introduced as the
selective therapeutic technique (11,14). It was
shown that fertility rate was more in hysteroscopy
myomectomy cases comparing to infertile patients
with normal cavity (5,11). In one study carried on
21 infertile women undergoing hysteroscopy and
myomectomy, pregnancy occurred in 11 cases in
2-6 months (15). According to some studies a
higher rate of success has been reported in
myomas≤ 30 mm comparing to larger myomas
(16). According to Varasteh et al (1999) study
hysteroscopic resection of a large myoma although
may ablate a large surface area of the endometrial
cavity, the reproductive benefit appears greater
than the risk (11). In other studies in infertile
women after septum resection, metroplasty and
deliberation of intrauterine
hysteroscope because of infertility, recurrent
abortion, ectopic pregnancy and preterm labor, an
increased rate in pregnancy was observed in
previously infertile patients, while a reduce rate in
spontaneous abortion cases (1,17)
The present study was aimed to evaluate
frequency distribution of pregnancy occurrence
after diagnostic-surgical hysteroscopy in patients
referring to Royan Infertility Center (Tehran, Iran)
because of reproductive problems.


Materials and methods

This study was
descriptive-analytic study. From all patients
referring to Royan Infertility Center (Tehran, Iran)
during October 2004 to October 2005, 115 patients
were scheduled for diagnostic and therapeutic
spontaneous abortion.
occurrence after
adhesions by
designed as a
hysteroscopy. Including criteria were having
abnormal finding in the endometrial sonography
(polyp, myoma, septation,
abnormalities, adhesion) at cycle day 14, abnormal
finding in uterine cavity (myoma, adhision, filling
defect, anatomical abnormalities) in HSG, history
of recurrent abortions and history of at least 4
unsuccessful IVF or ICSI cycle without any
confirmed diagnosis of abnormalities in uterine
cavity. After confirming general health, patients
were treated with decapeptid for 12 months. Then
they underwent diagnostic hysteroscopy under
general anesthesia and in the case of observing
septum, polyp, submocusal myoma or adhesion
hysteroscopic operation was performed. The
applied instruments were scissor, ring electrode,
forceps and resectoscope.
sonography and HSG were repeated 2-3 months
later and patients were followed for the occurrence
of spontaneous pregnancy or IUI, IVF and ICSI-
induced pregnancy for 12 months. The criteria for
pregnancy occurrence were positive ß-HCG and
observing gestational sac in the uterine cavity by
sonography.

Statistical analysis
The gathered data were analyzed by SPSS and
after describing data, variables were compared in
pregnant and non- pregnant groups by using Chi-
square test. In data analysis p<0.05 was considered
as statistically significant.

Results

Mean age of participants was 32.65 ± 6.12 years
and mean of infertility duration was 8.33 ± 5.25
years. According to the sonography performed
before hysteroscopy, 69.6% had abnormal finding
and 30.4% were normal. The results of HSG were
abnormal in 41.8% and normal in 39% of the
subjects. From all, 18.3% had no previous HSG.
According to the results of hysteroscopy, 65.2% of
the subjects were abnormal and 34.8% were
normal.
Among 80 cases with abnormal finding in
sonography, in 63 cases the abnormality was
confirmed by hysteroscopy while 17 cases were
reported normal. Among 70 cases with abnormal
finding in HSG, 55 cases were abnormal based on
hysteroscopy while 15 cases were normal. From all
patients who had been reported normal in
sonography, 23 cases were normal based on
hysteroscopy, while 12 cases had abnormal
findings in hysteroscopy and finally among those
with normal HSG, 20 cases had problem in
anatomical
Postoperative

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Hystroscopy and infertility
Iranian Journal of Reproductive Medicine Vol.5. No.3. Summer 2007
101
hysteroscopy too, while 25 cases were reported
normal.
Sensitivity and specificity of sonography were
respectively 84% and 57.5% and those of HSG
were respectively 73.3% and 62.5% (Tables I and
II), comparing to hysteroscopy as a gold standard
method.
Hysteroscopy findings were septum, polyp,
myoma, adhesion, endometrial irregularity and
bicornuate uterus and all cases with abnormality
underwent hysteroscopic surgery.
According to the postoperative sonography,
63.5% of the patients were normal and 24% were
abnormal.
From all patients, 27 cases became pregnant
during the first 6 postoperative months and 2 cases
during the second 6 postoperative months.
Pregnancy occurred without any intervention in 3
cases, after IUI in 4 cases and after IVF or ICSI in
22 cases. From 40 cases with normal hysteroscopy
reports, 14 cases (35%) and from 75 patients with
problem in hysteroscopy, 15 cases (20%) became
pregnant that shows no significant difference
between these two groups regarding the pregnancy


Table IV. Pregnancy rate after abnormal hysteroscopy

occurrence (p= 0.63, CI:95%) (Table III).

Table I. Diagnostic criteria in Hysteroscopy and Sonography

Hystersocopy
Sonography
Normal Abnormal
Normal 23 12
Total
35
Diagnostic
criteria
Sensitivity:
84%
Specificity:
57.5%
p<0.000
Abnormal 17 63 80

Total

40

75

115

Table II. Diagnostic criteria in Hysteroscopy and HSG

Hystersocopy
HSG
Normal Abnormal
Normal 25
Total
45
Diagnostic
criteria
Sensitivity:
73.3%
Specificity:
62.5%
p<0.000
20
Abnormal 15 55 70

Total

40

75


115
Table III. Pregnancy rate after Hysteroscopy


Pregnancy
Normal
+ 14 (35%)
Hysteroscopy



Abnormal
15 (20%)



Total
29
__ 26 (65%) 60 (80%) 86
Total 40 (100%) 75 (100%) 115
p = 0.63
Type of lesion
Septum
Pregnancy
Myoma Polip Adhision Arcuate

Total
+
-
2
12
14
5
13
18
6
29
35
1
2
3
1
1
2
15
57
72 Total

Table V. Type of lesions in HSG, Sonography and hysteroscopy

Type of lesion
Adhision
Method
Normal Myoma Polyp Anatomical
abnormality
29
11
38

Total
HSG
Sonography
Hesteroscopy
45
35
40
6
23
14
14
5
5
- 94
90
115
16
18

Discussion

In uterine disorders affecting productivity,
hysteroscopy is the most accurate technique for
diagnosis and treatment. By hysteroscopy, direct
observation of the uterine cavity regarding its
shape, size and location is possible (18). Operative
hysteroscopy can be used for removal of uterine
myoma and polyps or correction of uterine septum
and adhesions. Hysteroscopy in comparison to
abdominal metroplasty has improved fertility rate
significantly and has lead to less complications.
Suspected uterine polyps can be operated
successfully by using hysteroscope (2). In infertile
women, hysterosalpingography is the first and best
imaging technique that can be followed by
hysteroscopy in order to confirm the diagnosis.
Due to the high prevalence of false negative results
in radiographic images of women with uterine
abnormalities (2) some suggest hysteroscopic
investigation as an
According to Lee et al (1997) HSG is a specific but
not sensitive predictor of uterine pathology in
patients population. Tubal ostial polyps may occur
in a significant proportion of infertile patients and
can cause proximal tubal occlusion on HSG (12).
The obtained sensitivity and specificity for HSG
(73.3% and 62.5% respectively, K= 0.34) and
transvaginal sonography
respectively, K= 0.42) in the present study, show
obligatory technique.
(84% and 57.5%

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Shahrokh Tehrani Nejad et al
Iranian Journal of Reproductive Medicine Vol.5. No.3. Summer 2007
102
the importance of hysteroscopy as a diagnostic
technique.
In several studies improvement in fertility rate
following hysteroscopic operations has been
observed. In Szymanski et al study (2000) 24% of
patients became pregnant after myomectomy,
septum resection and deliberation of intrauterine
adhesions (17).
Sanders (2006) in a literature review about
reported case series, demonstrated a reduction in
the spontaneous abortion rate from 91% to 17% on
average after hysteroscopic metroplasty and 47%
pregnancy rate in previous infertile patients and
78% pregnancy rate
polypectomy compared to 42% in infertile patients
with normal endometrial cavities (6).
Shokeir et al (2004) suggested that diagnostic
hysteroscopy should be used routinely in the work-
up of infertile women because presence of
eumenorrhea persistent functional endometrial
polyps, even if small, are likely to impair fertility.
Removal of such lesions may improve subsequent
reproductive performance (8). In two other studies
by Perez-medina et al (2005) and Spiewankiewicz
et al (2003) 65% and 80% of the patients
undergoing surgery were conceived (7,9).
Similarity, in the present study, 35% of the
subjects with normal hysteroscopy findings and
20% of the subjects with abnormal finding in
hysteroscopy who underwent
surgery became pregnant during one year without
any intervention or by assisted reproductive
techniques. Although the difference is not
significant (p= 0.63), it shows that the infertility
factor has not been limited to uterine cavity
abnormalities and various factors may have been
involved in the studied patients. Therefore longer
follow up and were frequent ART cycles are
needed. It is certain that abnormalities in uterine
cavity should be treated and improvement and
revision in techniques of hysteroscopic surgeries
can definitely improve the results. These
techniques include using
instruments (laser instead of electric electrodes and
preventing thermal damage),
laparoscopy and hysteroscopy in special cases and
removal of remained lesions after hysteroscopy
(such as interamular myomas) by second
operation.

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