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The value of repeat hysteroscopic evaluation in patients with failed in vitro fertilisation cycles
Abstract
One hundred ten women with normal initial hysteroscopy who failed to conceive during three or more IVF-ET cycles underwent repeat hysteroscopic evaluation. In 20 patients (18.2%), visualization revealed uterine abnormalities, mainly newly added endometrial lesions, i.e., hyperplasia, polyps, endometritis, and synechiae. Our results indicate that repeat hysteroscopic evaluation, in cases of recurrent IVF-ET failure, is an important adjunctive method for further evaluating and possibly optimizing the IVF-ET procedure.
... The inclusion of hysteroscopy in ART shows that these patients have higher endocavitary pathology. Dicker (1992) studied the incidence of unsuspected endouterine abnormalities in IVF patients who failed to conceive during three or more cycles. They underwent repeated hysteroscopy evaluation and he found pathology in 18% of the patients. ...
... After hysteroscopy correction in 43 IVF cycles studied, 14 pregnancies were achieved. 18 These results indicate that repeated hysteroscopy evaluation in cases of recurrent IVF failure is an important adjunctive tool for further evaluating and possibly optimizing IVF procedure. The role of hysteroscopy in the evaluation of the endometrial cavity, especially in the unexplained infertility before IVF, is generally accepted. ...
... According to the results of our study, abnormal hysteroscopic findings were observed in 59.5% of the cases with unexplained repeated IVF failures which is higher than the result of previous studies due to exclusion of the other possible reasons of repeated ET failures like, thromobophilia, chromosomal and immunologic factors. Dicker et al showed, uterine abnormalities were detected in about 18% women with normal initial hysteroscopy who had three or more IVF-ET failures and underwent repeated hysteroscopy (15). Also Schiano et al showed abnormalities in half of the cases like cervical abnormalities (synechia, polyp, and false passage) and hormonal-dependent abnormalities (polyp, hyperplasia, submucous myoma) in repeated uterine hysteroscopy after two implantation failures in IVF (13). ...
... Dicker study showed, that in elderly women, age-related uterine pathology such as submucous myoma, endometrial hyperplasia, and polyps were more prominent, while in younger patients other uterine lesions such as adhesions and tubal ostia occlusion were more common (15). In our experiences, we have seen single polyp and endometrial hyperplasia more in the patients with ≥30years olds rather than the younger group (p-value= 0.78). ...
Background: Despite numerous developments in the field of assisted reproduction, theimplantation rate remains low. Among the various reasons of implantation failure,endometrial regularity has an important role. Hysteroscopy is an accurate method forevaluating the endometrial characteristics, with the ability to treat uterine pathology.Objective: The aim of the present study was to evaluate the findings on hysteroscopyand thereafter the result of subsequent IVF/ICSI in infertile women with the history offrequent unexplained and unsuccessful IVF/ICSI attempts.Materials and Methods: In this observational study, the hysteroscopy findings and theoutcomes of subsequent IVF/ICSI were evaluated in 89 infertile women admitted inAvicenna Infertility Clinic, with previous repeated (more than two) failed IVF/ICSIETs,including the patients with normal Hysterosalpinography (HSG) and excludingsevere male factor infertility and also thrombophilia, genetic and immunologicproblems. The data were analyzed with SPSS software and Fisher exact, chi-square, andMC-Nemar tests.Results: In 53 (59.5%) cases, hysteroscopy revealed abnormal intrauterine findingsincluding adhesions 7 (13.7%), single polyp 11 (20.7%), endometrial polyposis 10(18.8%), endometrial hyperplasia 10 (18.8%), uterine cavity hypoplasia 4 (7.8%) andmyoma 5 (9.8%). These abnormalities were significantly higher in women with morethan 8 years of infertility (chi-square=4.7, p-value=0.03). After hysteroscopy andsubsequent IVF/ICSI-ET attempt using standard long protocol, pregnancy rate weresignificantly higher compared with the previous repeated IVF/ICSI attempts (35.8%versus 0%).Conclusion: According to this study, we strongly suggest evaluation of endometrialintegrity by hysteroscopy in patients with repeated IVF/ICSI-ETs failure, beforeentering any other fertilization procedures.
... oscopy and transvaginal hydrolaparoscopy, perhaps together with a transcervical dye test and a transvaginal salpingoscopy, anatomic conditions of the internal genital tract can sufficiently be evaluated in the office environment (Gordts et al., 1998 and unpublished observations). Thus hysterosalpingography or contrast sonography are made redundant. Dicker et al. (1992) demonstrated the value of repeated hysteroscopy in in-vitro fertilization (IVF)–embryo transfer patients in whom, without obvious reason, pregnancy did not occur. In 110 women with normal hysteroscopic findings and three or more failed IVF–embryo transfer cycles they performed a control hysteroscopy. They found in 20 cases (18.2%) abnor ...
... In 110 women with normal hysteroscopic findings and three or more failed IVF–embryo transfer cycles they performed a control hysteroscopy. They found in 20 cases (18.2%) abnormal findings possibly being the cause for the implantation failure (Dicker et al., 1992 ). In our own prospective registration of 530 consecutively performed office minihysteroscopies we found significant pathology in 151 patients (Table VIII). ...
The technique of diagnostic hysteroscopy has not yet been accepted generally as an ambulatory, well-tolerated office procedure. Especially in the infertile patient the standard hysteroscopic procedure is poorly tolerated in an office environment. Our prospective registration of 530 diagnostic office mini-hysteroscopies in infertile patients demonstrates that using an atraumatic insertion technique, watery distention medium and the new generation of mini-hysteroscopic endoscopes, hysteroscopy can be performed in an office set-up without any form of anaesthesia and with a high patient compliance. The significant number of abnormal findings (28.5%), the absence of complications and the low failure rate (2.3%) indicate that diagnostic office mini-hysteroscopy should be a first-line diagnostic procedure. Those results are compared with the registration of 4204 consecutive conventional diagnostic hysteroscopies in a routine gynaecological population performed between 1982 and 1989. We conclude that the mini-hysteroscopic system offers a simple, safe and efficient diagnostic method in the office for the investigation of abnormal uterine bleeding, to evaluate the cervix and uterine cavity in the infertile patient, for screening of endometrial changes in patients under hormone replacement therapy or anti-oestrogens as (adjuvant) treatment and, lastly, it may be very helpful for the interpretation of uncertain findings in other diagnostic techniques such as ultrasound, magnetic resonance imaging, blind biopsy or hysterosalpingography.
... 1,2 Assessment of the uterine cavity by hysteroscopy was traditionally recommended for patients with recurrent assisted reproduction treatment (ART) failures. [3][4][5][6] However, a recent systematic review showed that, in some clinics, hysteroscopy is currently offered even before the first IVF attempt. 7 Indeed, accumulating evidence suggests that hysteroscopy has a higher diagnostic accuracy to detect uterine cavity pathologies than hysterosalpingography, especially in infertile women. ...
Objective
To analyze the cost‐effectiveness of virtual sonographic hysteroscopy (VSH) performed before in vitro fertilization (IVF) (Scenario 1), frozen embryo transfer (Scenario 2), and oocyte donation (Scenario 3) attempts.
Methods
A retrospective analysis of data extracted from patients’ files was conducted. Before undergoing the assigned treatment, VSH was offered to all patients. Cost‐effectiveness was calculated on the basis of cost per live birth. The total cost was compared with a control group of patients who declined to have hysteroscopy before their treatment.
Results
A total of 292 women were involved. Virtual sonographic hysteroscopy was performed in 192 women. Conventional operative hysteroscopy was subsequently required in 34 of them (17.7%). Subsequent assisted reproduction attempts resulted in live birth in 111 women—34/69 (49.3%), 35/69 (50.7%), and 42/54 (77.8%) in Scenarios 1, 2, and 3, respectively. This compared favorably with 100 women who declined VSH, with live birth achieved in 15/39 (38.5%), 14/37 (37.8%), and 15/24 (62.5%) in Scenarios 1, 2, and 3, respectively. The overall cost‐effectiveness of VSH compared favorably with straightforward treatment performed without this test.
Conclusion
The overall cost‐effectiveness of treatment attempts carried out after previous VSH compared favorably with straightforward treatment performed without this test.
... [11] also, uterine cavity assessment by hysteroscopy has been demonstrated to be useful in women with two IVF failures. [12,13] Hence, hysteroscopy has become one of the common investigations proposed after RIF. [14] SIS is a technique in which a catheter is placed into the endometrial cavity, and sterile saline is instilled to separate the walls of the endometrium. ...
Aim:
This study aims to determine the accuracy of saline infusion sonohysterography (SIS) in the diagnosis of intrauterine pathologies in women with recurrent implantation failure (RIF).
Settings and design:
This is a prospective cross-over study which was carried out during the period between December 2013 and July 2014.
Materials and methods:
The study involved sixty subfertile women with a history of RIF. All cases underwent a transvaginal ultrasonography, SIS and then an office hysteroscopy (1 day after SIS) during early follicular phase. SIS was carried out by same sonographer, and then hysteroscopy was carried out by same gynecologist who was kept blind to findings at SIS.
Statistical analysis:
Was done using IBM(©) SPSS(©) Statistics version 22. The sensitivity of SIS was calculated as it equals: True positive by SIS/all positive (true cases by hysteroscopy) and specificity was calculated as it equals: True negative by SIS/all negatives (normal by hysteroscopy).
Results:
Overall uterine abnormalities were significantly less likely to be identified with SIS compared to hysteroscopy (P = 0.002), but analysis of each finding separately demonstrated a comparable difference between SIS and hysteroscopy (P > 0.05). We found that the sensitivity, specificity, positive predictive value, and negative predictive value of SIS to detect intrauterine pathology is 41.2%, 100%, 100%, and 81.1%, respectively.
Conclusion:
Our findings suggest a good role of SIS in the workup for RIF saving more invasive procedure for selected cases.
... One of the most beneficial impacts of oHS is the correction of specific uterine cavity abnormalities when detected. Endometrial polyps and different degrees of adhesions are the most common findings in women with RIF in the literature and in our data as well (2,17). Adhesions are likely to be unrecognized with TVS during initial follow-up, and they should be better removed when detected in order to maintain successful implantation (18)(19)(20). ...
Objective:
Repeated implantation failure (RIF) is a clinical entity affecting many couples undergoing assisted reproductive technology (ART). Various intrauterine pathologies contribute to RIF. Nevertheless, vaginal sonography and hysterosalpingography, which are the common diagnostic tools for the initial follow-up, have limited sensitivities. In this context, we aimed to evaluate the impact of office hysteroscopy (oHS) on live birth rates (LBRs) when performed prior to subsequent ART cycles in women with a history of RIF.
Material and methods:
The database of an assisted reproduction center was retrospectively reviewed to detect eligible cases. A total of 363 women out of 2875 admissions were consecutively included in the analysis, of which 119 formed the oHS group and 244 formed the non-oHS group prior to a new ART cycle. Women in the oHS arm were examined during their early follicular phase via a vaginoscopic approach 1-6 months before the beginning of a new cycle. The standard in-vitro fertilization-intracytoplasmic sperm injection (IVF/ICSI) cycle was applied to all the women.
Results:
In the oHS group (n=119), 61 patients had intrauterine abnormalities, with an overall abnormality rate of 51.2%. Implantation, pregnancy, and LBRs of the groups were statistically similar. LBRs of the women with abnormal oHS findings (15/61, 24.5%), with normal oHS findings (14/58, 24.1%), and without oHS (39/244, 16%) were statistically similar (p=0.41).
Conclusion:
Unrecognized intrauterine pathologies can be easily detected and concurrently treated during oHS with high success rate. However, a beneficial impact depends on the extent of the pathology and thus, routine application to enhance reproductive outcomes is still not warranted.
... 7,8 Hysteroscopy allows visual assessment of the cervical canal and uterine cavity and provides the opportunity to operate in the same setting. [8][9][10][11] Routine outpatient hysteroscopy before starting IVF has been postulated to diagnose and treat abnormalities of the cervix and uterine cavity and hence improve IVF outcome. [12][13][14] A systematic review of published studies suggested that outpatient hysteroscopy in the menstrual cycle preceding an IVF treatment cycle could significantly increase the clinical pregnancy rate in women who had previously had recurrent implantation failure, even when no hysteroscopic abnormality was detected. ...
Background:
The success rate of in-vitro fertilisation (IVF) remains low and many women undergo multiple treatment cycles. A previous meta-analysis suggested hysteroscopy could improve outcomes in women who have had recurrent implantation failure; however, studies were of poor quality and a definitive randomised trial was needed. In the TROPHY trial we aimed to assess whether hysteroscopy improves the livebirth rate following IVF treatment in women with recurrent failure of implantation.
Methods:
We did a multicentre, randomised controlled trial in eight hospitals in the UK, Belgium, Italy, and the Czech Republic. We recruited women younger than 38 years who had normal ultrasound of the uterine cavity and history of two to four unsuccessful IVF cycles. We used an independent web-based trial management system to randomly assign (1:1) women to receive outpatient hysteroscopy (hysteroscopy group) or no hysteroscopy (control group) in the month before starting a treatment cycle of IVF (with or without intracytoplasmic sperm injection). A computer-based algorithm minimised for key prognostic variables: age, body-mass index, basal follicle-stimulating hormone concentration, and the number of previous failed IVF cycles. The order of group assignment was masked to the researchers at the time of recruitment and randomisation. Embryologists involved in the embryo transfer were masked to group allocation, but physicians doing the procedure knew of group assignment and had hysteroscopy findings accessible. Participants were not masked to their group assignment. The primary outcome was the livebirth rate (proportion of women who had a live baby beyond 24 weeks of gestation) in the intention-to-treat population. The trial was registered with the ISRCTN Registry, ISRCTN35859078.
Findings:
Between Jan 1, 2010, and Dec 31, 2013, we randomly assigned 350 women to the hysteroscopy group and 352 women to the control group. 102 (29%) of women in the hysteroscopy group had a livebirth after IVF compared with 102 (29%) women in the control group (risk ratio 1·0, 95% CI 0·79-1·25; p=0·96). No hysteroscopy-related adverse events were reported.
Interpretation:
Outpatient hysteroscopy before IVF in women with a normal ultrasound of the uterine cavity and a history of unsuccessful IVF treatment cycles does not improve the livebirth rate. Further research into the effectiveness of surgical correction of specific uterine cavity abnormalities before IVF is warranted.
Funding:
European Society of Human Reproduction and Embryology, European Society for Gynaecological Endoscopy.
... 7,8 Hysteroscopy allows visual assessment of the cervical canal and uterine cavity and provides the opportunity to operate in the same setting. [8][9][10][11] Routine outpatient hysteroscopy before starting IVF has been postulated to diagnose and treat abnormalities of the cervix and uterine cavity and hence improve IVF outcome. [12][13][14] A systematic review of published studies suggested that outpatient hysteroscopy in the menstrual cycle preceding an IVF treatment cycle could signifi cantly increase the clinical pregnancy rate in women who had previously had recurrent implantation failure, even when no hysteroscopic abnormality was detected. ...
... Danas je zvanični stav da se histeroskopija preporučuje bolesnicama sa sumnjom na postojanje intrauterine patologije u cilju njenog lečenja i uklanjanja, kao i nakon ponavljanih neuspeha IVF postupaka, a poznato je da do 50% infertilnih bolesnica ima intrauterine abnormalnosti [3][4][5][6][7] . ...
Implantation failure after embryo transfer is one of the main problems of in vitro fertilization (IVF) and intrauterine pathologies can lead to unsuccessful outcome. The aim of this study was to determine if hysteroscopic examination of uterine cavity and consequent treatment of intrauterine lesions prior to IVF could improve the pregnancy rate in women under 38.
This study included 480 patients under 38, who had undergone IVF or IVF\ICSI--embryo transfer cycles, in which one or more good quality embryos were transferred. By transvaginal sonography performed within the past 2 months, the uterus was found normal in all the patients enrolled in our IVF unit. The patients were divided into three groups: group A--with no hysteroscopic evaluation and no pathology, group B --with hysteroscopy but no pathology, and group C--with abnormal hysteroscopy finding and corresponding treatment.
The obtained results revaled no difference in the mean age, duration of infertility, number of mature oocytes in either group (p > 0.05). Clinical pregnancy rates in the groups A, B and C were 36.9%, 58.75% and 32.7%, respectively, and delivery rates were 27.5%, 48.7% and 25.7%, respectively. There was a statistically significant difference among the groups concerning pregnancy and delivery rates.
Considering the results of this study we could conclude that hysteroscopy, as a routine examination, should be performed before the first IVF-ET cycle in all patients thereby reducing the failures and then the costs of IVF-ET.
... One of the common investigations proposed after recurrent IVF failure is outpatient hysteroscopy (OH). OH is a well-tolerated minimally-invasive procedure, which allows reliable visual assessment of the cervical canal and uterine cavity and provides the opportunity to perform therapy in the same setting [5,[8][9][10][11]. Intra-uterine pathologies have been shown to be present in 25% of infertile patients [11]. ...
Background
The success rate of IVF treatment is low. A recent systematic review and meta-analysis found that the outcome of IVF treatment could be improved in patients who have experienced recurrent implantation failure if an outpatient hysteroscopy (OH) is performed before starting the new treatment cycle. However, the trials were of variable quality, leading to a call for a large and high-quality randomised trial. This protocol describes a multi-centre randomised controlled trial to test the hypothesis that performing an OH prior to starting an IVF cycle improves the live birth rate of the subsequent IVF cycle in women who have experienced two to four failed IVF cycles.
Methods and design
Eligible and consenting women will be randomised to either OH or no OH using an internet based trial management programme that ensures allocation concealment and employs minimisation for important stratification variables including age, body mass index, basal follicle stimulating hormone level and number of previous failed IVF cycles. The primary outcome is live birth rate per IVF cycle started. Other outcomes include implantation, clinical pregnancy and miscarriage rates.
The sample size for this study has been estimated as 758 participants with 379 participants in each arm. Interim analysis will be conducted by an independent Data Monitoring Committee (DMC), and final analysis will be by intention to treat. A favourable ethical opinion has been obtained (REC reference: 09/H0804/32).
Trail Registration
The trial has been assigned the following ISRCTN number: ISRCTN35859078
... Particular usefulness of operative HS has been shown in infertility patients undergoing in vitro fertilization with embryo transfer (IVF/ET) by noting that 19% had intrauterine or cervical abnormalities that were not diagnosed on previous HSG evaluation (7). It has further been shown in patients who have had a normal baseline HS and repeat failed IVF/ET attempts that on repeat HS evaluation, newly acquired intrauterine abnormalities were found in 18%-28% (7,8). ...
To compare the diagnostic accuracy, pain scores, and procedure length of outpatient hysteroscopy (OHS), hysterosalpingography (HSG), and saline infusion hysterosonography (SIS) for evaluation of the uterine cavity of infertile women.
Prospective, randomized, investigator-blind study.
Tertiary infertility clinic.
Forty-six consecutive infertile women.
Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS).
Uterine abnormalities, procedure length, and subjective pain.
Fifty-nine percent of infertile subjects were found to have an abnormality on at least one of three outpatient uterine evaluations. When compared with the case of definitive operative HS, 60% of abnormalities were correctly classified by HSG, 72% by OHS, and 52% by SIS (P: NS). When comparing all combinations of 2 outpatient screening tests to operative hysteroscopy, 68% were correctly classified by HSG/OHS, 58% by HSG/SIS, and 64% by OHS/SIS (P: NS). The average time length for the OHS was 9.1 min., which was significantly greater than for both HSG (average, 5.3 min) and SIS (average, 6.1 min.) (P<.0001 for both). HSG and SIS were not statistically different regarding procedure time length. The average pain score (0-10) for SIS was 2.7, compared with 5.8 and 5.3 for HSG and OHS, respectively. Both HSG and OHS mean pain scores were significantly greater than the SIS mean.
OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness and safety of screening hysteroscopy in subfertile women undergoing evaluation for infertility and subfertile women undergoing IVF.
The success rate of In Vitro Fertilization (IVF) procedure is partly dependent on the ability to transfer embryos within a uterine cavity appropriate for implantation. Indeed, it is has been shown that cervical canal, uterine cavity and endometrial abnomalities may interfer with embryo replacement and implantation [1]. However, the significance of mild intrauterine or cervical pathology is still unknown and the actual incidence of severe abnomalities has been differently appreciated [2,3]. Consequently, the rationale for a systematic evaluation of the uterine cavity is still questionable. To address this issue, we will consider different clinical situations which are usually encountered in our clinical practice and we will discuss the exact place of hysteroscopy which is an useful tool to evaluate uterine cavity [4].
Conventional rigid hysteroscopy started in 1869 with Pantaleoni (Great Britain). The first fibroscope was presented 94 years later by Mohri and Mohri (Japan) in 1963. For the last 36 years, fibrohysteroscopes have developed tremendously because of the continuous improvement of the optic fibers. This progress has allowed to manufacture ultraslim hysteroscopes with superior resolution and brightness, that enable the physician to work on an outpatient basis.
Objective(s):
To evaluate the effect of hysteroscopic polypectomy during ovarian stimulation phase on in vitro fertilization and/or intracytoplasmic sperm injection (IVF/ICSI) cycles outcomes.
Study design:
This cross sectional study was performed in female infertility department of Royan Institute from January 2011 to December 2013. In total, 160 patients who were diagnosed incidentally polyp/polyps less than 20mm during the stimulation phase for oocyte recoveries were recruited; of these, fifty eight cases underwent hysteroscopic polypectomy without cycle cancellation non-randomly. Polyp resection was performed through hysteroscopic polypectomy during ovarian stimulation. The interval between polypectomy and embryo transfer (ET) was 3-17 days. The women who did not undergo hysteroscopic polypectomy and matched for polyp size were selected as control group. The outcomes of IVF/ICSI cycles were compared between groups.
Results:
The data analysis showed the two groups were comparable in terms of patients' characteristics and stimulation outcomes. The implantation rate was not significantly different between groups (P=0.3). The clinical pregnancy and live birth rates were similar between groups (%34.9 vs. %32.5 and %30.2 vs. %27.9, P=0.9 and P=0.8). No pregnancy was observed in patients who had the interval between hysteroscopic polypectomy until ET less than 5days and the multivariable logistic regression analysis revealed that the interval between polyp resection and ET was significant predictor for live birth rate (odds ratio: 1.2, confidence interval: 1.01-1.5, P=0.04).
Discussion(s):
For the management of the polyps less than 20mm which have been diagnosed during the stimulation phase, the performance of hysteroscopic polypectomy without cycle cancellation does not improve the pregnancy and live birth rates. Therefore, it seems that the continuation of the treatment cycle and ignorance of these polyps is the appropriate treatment choice and the performance of hysteroscopic polypectomy and frozen embryo transfer program could be the next treatment option.
A thorough review of the literature regarding the modalities employed for diagnosis of endometrial polyps and their impact on infertility is presented.
Endometrial polyps are responsible for approximately one-fourth of cases of abnormal genital bleeding in both premenopausal and postmenopausal women. They can be hyperplastic, atrophic, or functional and are rarely associated with malignancy.
As recommended by the 2012 AAGL guidelines, transvaginal ultrasound is the initial imaging of choice, with MRI reserved for indeterminate cases or where sampling is difficult.
The frequency of unrecognized intrauterine pathologies in patients with recurrent implantation failure can vary from as low as 18 % to as high as 50 %. Even though endometrial polyps are the most common pathology found in these patients, it is controversial whether they contribute to infertility or poor pregnancy outcomes. However, it is plausible that polyps can cause infertility due to mechanical interference with sperm and embryo transport, impairment of embryo implantation, or altered endometrial receptivity. Furthermore, the size, number, or location of polyps may influence any effect on reproductive outcomes.
Hysteroscopic removal of endometrial polyps appears to improve spontaneous pregnancy rates in women with otherwise unexplained infertility. For patients with infertility and polyps, removal of disease is likely to be helpful to subsequent pregnancy.
INTRODUCTION: Previous reports have suggested that hysteroscopically detectable uterine abnormalities are present in approximately 45% of patients undergoing "in vitro fertilization". This study is an attempt to evaluate if hysteroscopy evaluation before the use of assisted reproduction techniques is of value in detecting undiagnosed or misinterpreted uterine abnormalities. MATERIAL E METHODS: Diagnostic hysteroscopy was carried out on 230 patients before the use of assisted reproduction techniques (IVF ICSI and oocyte donation). The examination was performed on an ambulatory basis during the first phase of the menstrual cycle using local anesthesia with bilateral paracervical block. Distension of uterine cavity was performed with CO 2. Hysterometry was evaluated, as well as the type of ideal catheter to be used at the time of embryo transfer. RESULTS: The uterine cavity did not present any changes in 152 patients (66%) but some type of pathology was visualized in 78 patients (34%). Vascular changes suggestive of endomethtis were detected in 44 patients (19.1 %), endoimetrial polyps in 17 (7.4%), synechiae or adhesions in 10 (4.4%), mullerian anomalies in 4 (1.8%), and submucosal myomas in 3 (1.3%). CONCLUSION: Diagnostic hysteroscopy is an exam that should be routinely performed before the use of assisted reproduction techniques, facilitating the identification of diseases that may eventually interfere with the process of embryo implantation and also permitting an accurate evaluation of the cervical canal and uterine cavity, fundamental marks for an ideal embryo transfer.
Aromatase expression in the eutopic endometrium is triggered by constant exposure to inflammatory mediators such as prostaglandins, which are produced during menstruation and in the proliferative phase of the menstrual cycle. The presence of aromatase in the endometrial cells is pivotal for the development of endometriosis in the peritoneal cavity, since local estrogen production may be the mechanism that suppresses the phagocytosis of these cells by macrophages and NK cells. The severity of endometriosis correlates positively with the intensity of aromatase expression in the eutopic endometrium, thus corroborating the hypothesis that the progression of endometriosis depends on the constant shedding of aromatase-positive cells through retrograde menstruation. The coexistence of other pathologies with endometriosis is also associated with the presence of aromatase expression in the endometrium. This has been observed in cases of submucous/intramural myomas, endometrial polyps and adenomyosis. In all these cases, the presence of aromatase was associated with increased inflammation in the endometrium as determined by the presence of NF-kappa.B in cell nuclei. The number of NF-kappa.B-positive nuclei was significantly greater in the endometrium of pathology-harboring uteri compared to normal controls. This was observed both during the proliferative phase and prior to the onset of menstruation, thus suggesting a proinflammatory role for estrogens and an antiinflammatory effect of progesterone in the endometrium. Endogenous progesterone or progestins such as gestodene or levonorgestrel when used orally or delivered locally in the uterine cavity are potent inhibitors of aromatase expression in the endometrium and this effect probably involves gene-silencing through transcription inhibition. The decrease in aromatase expression induced by progestins was accompanied by a reduction in the expression of enzymes such as cyclooxygenase type 2 (Cox-2) or angiogenic factors such as VEGF in the endometrium. Inflammation in the endometrium was also diminished by progesterone or progestins and this mechanism involved the inhibition of NF-kappa.B activation. These findings support the role of progestins as anti-aromatase and antiinflammatory agents in the current management of endometriosis and other gynecological pathologies. In fact, the continuous use of combined oral contraceptives containing gestodene or the use of levonorgestrel-releasing intrauterine systems were found to be effective in preventing not only the recurrence of endometriosis but also myoma-related menorrhagia, thereby supporting the causal relationship between aberrant aromatase expression in the endometrium, inflammation and the development of pathology.
Objective: Empirically, hysteroscopy before IVF has been suggested to be performed in women with repeated IVF failures. We aimed to analyse the basis for this indication, and also, to determine other possible predictors for a uterine pathology before an IVF cycle. Materials and Methods: One-hundred-seventy-six consecutively seen women, who were screened for an intrauterine pathology before the IVF cycle by using office hysteroscopy, were analysed in this retrospective analysis. Women with an endometrial pathology were compared to those without any pathology with respect to their clinical characteristics, such as age, duration of infertility, type of infertility, history of previous curettage, cause of infertility and number of previous embryo transfers. Logistic regression analysis was used for the statistical analysis. Results: In 16% of subjects, a pathology was observed; 39% of these women had endometrial polyps, 32% had endometrial adhesions, 18% had uterine septum and 11% had leiomyomas. Regression analysis revealed that the number of previous IVF-ET failures was the only predictor for a uterine pathology. Women with at least one IVF-ET failure were 2.7 times more likely to have an endometrial pathology than those, who had no failures. Odds ratios were 3.2 for women with two or more failures, and 4.7 for those with three or more failures. There was an increasing trend in odds ratios with increasing number of IVF failures. Conclusion: Women with any previous number of IVF failures are good candidates for screening for endometrial pathology before IVF. Increasing number of failures increases the risk for detecting a lesion in the cavity.
Introduction
Inclusion in an IVF program requires several additional morphological examinations such as pelvic ultrasound, hysterosalpingography (HSG) and hysteroscopy. The exploration of the uterine cavity is an essential step and the contribution of each of these morphological examinations is variably appreciated.
Aim
To evaluate the contribution of hysteroscopy prior to the first IVF/ICSI attempt when compared to the couple pelvic ultrasound and hysterosalpingography and to estimate the correlation between these three exams.
Material and patients
This is a retrospective study including 94 patients, included in an IVF program, in the assisted reproductive techniques center of Aziza Othmana hospital of Tunis, during a period of one year, from January 1 to December 31 2009.
Results
The hysterography has a specificity of 85.71% and overall sensitivity of 39.47%, with a strong correlation with hysteroscopy. Ultrasound has, in turn, an overall specificity of 82.35% and a sensitivity of 35.29%, with a moderate correlation with hysteroscopy. Combining the results of ultrasound and hysteroscopy, this couple has a sensitivity of 72.97% if at least one of them is pathological. The pair (echo/HSG) has a specificity of 92.68% if both tests are concordant.
Conclusion
The couple pelvic ultrasound and hysterosalpingography could avoid the use of hysteroscopy prior to an IVF program, provided they are concordant.
More than 1% of the couples whishing children suffer from recurrent miscarriage, but investigations and treatment are not consensual. Most patients have several risk factors, and a minimum investigation of known factors has to be undertaken: karyotyping of the couple, hysteroscopy for searching uterine anatomic anomalies, evaluation for thrombophilias (anticardiolipin antibodies, lupus anticoagulant, protein C activity, Proteine S activity, factor V Leiden and factor II mutations, activated protein C resistance), antinuclear antibodies. Systemic diseases (like lupus) and endocrine abnormalities (like thyroid diseases and diabetes mellitus) have to be detected by clinical examination and questioning. No endocrine investigation is recommended, unless irregular menstruations or sterility. Research in recurrent pregnancy loss are conducted in new associated factors, such as skewed-X-chromosome inactivation, maternal HLA types, modifications in specific immune molecules and cells regulation. Therapeutic proposals are preimplantation genetic diagnosis in case of abnormal karyotiping, hysteroscopic surgery for septate uterus, aspirin plus heparin in antiphospholipid-positive patients, and aspirin plus corticosteroids in systemic lupus. Heparin seems to improve obstetrical prognosis for patients with congenital or acquired thrombophilias, but there are only few studies carried out on the subject. This new therapeutic approach should incite the patients with a negative medical appraisal to be referred to specialized consultations in order to include them in eventual clinical tests. Finally, empathic listening and psychological support are necessary in a pathology with multiple etiological factors.
La place de la chirurgie dans la prise en charge du couple infertile demeure un sujet de controverses. Les bons résultats de l’assistance médicale à la procréation ont contribué à la diminution des indications chirurgicales dans la prise en charge des patientes infertiles. À travers une revue exhaustive de la littérature, nous avons sélectionné les articles les plus pertinents dans un but d’établir des recommandations pour la pratique clinique, basées sur l’évidence scientifique, concernant les indications et les bénéfices de la chirurgie dans le traitement des principales causes de l’infertilité féminine.
Introduction: Infertility related to the uterine cavity is the etiologic factor most commonly found in the 10% to 15% of the cases. Hysterosalpingography (HSG) is the routine evaluation technique of the uterine cavity to determinate congenital or acquired alterations; normally when we suspect uterine pathology by HSG we proceed to do a hysteroscopy. Previous reports in the existing literature have described that a routine office hysteroscopy in patients designated to IVF demonstrate 19% of uterine anomalies, which were not detected by HSG. Objective: Evaluation of diagnostic sensibility and tolerability of the office hysteroscopy without anesthesia in patients programmed for IVF with normal HSG. Design: Prospective and observational study. Materials and methods: We included 40 infertile patients programmed for IVF from December 02 to December 03. In all of them we made an office hysteroscopy with a 3 mm Bettocchi set. We did not use any kind of anesthesia. Results: In nine cases (22.5%), we found uterine anomalies, which were not diagnosticated by HSG; suggestive lesions of adenomyosis (two cases), endometrial polyps plus Asherman syndrome (one case), uterine septums (two cases), submucosus myoma (two cases), endometrial polyps (three cases). All the procedures were well tolerated. Conclusion: In conclusion, due to our findings, we assert the justification of a routine office hysteroscopy in patients before their IVF cycle.
Objective. – To evaluate the benefits of a diagnostic hysteroscopy prior to in vitro fertilization.Patients and methods. – We retrospectively studied 145 patients who underwent ICSI during a period of 6 months. Office hysteroscopy was systematically performed before the first stimulation cycle. If pathological findings were revealed, appropriate medical or surgical treatment was given.Results. – Pathological patterns were observed in 45% of hysteroscopies. Endometritis, polyps and myomas and mucosal diseases were the most frequently observed. The patients aged over 38 years didn’t show higher rate of pathology (29% vs 27% for the younger patients). The treatment of pathologies gave the same pregnancy rate than the normal cavities. Patients with endometritis were treated with antibiotics and 40% of them became pregnant in the following cycle.Discussion and conclusion. – Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.
Objective
To determine the accuracy of hysterosalpingography compared with hysteroscopy for detection of intrauterine abnormalities in infertile patients.
Design
Cross‐sectional study.
Setting
University hospital.
Subjects
296 women undergoing an assisted fertilization programme.
Intervention
Patients Underwent to hysteroscopy and hysterosalpingography prior to intrauterine insemination or in vitro fertilization.
Main outcome measures
Hysterosalpingographic and hysteroscopic findings.
Results
Hysteroscopy proved satisfactory in 90.5% of cases. Of the patients, 121 (40.9%) had an abnormal hysteroscopic evaluation. The most prevalent hysteroscopic findings were: cervical stenosis ( n = 28); chronic endometritis ( n = 17); synechiae ( n = 16); suspected endometrial hyperplasia ( n = 14); polyps ( n = 11); and myomas ( n = 7). The comparison of hysteroscopic and hysterosalpingographic findings revealed a sensitivity of 75.21% and a specificity of 41.14% for hysterosalpingography; the positive and negative predictive values were 47% and 70.60%, respectively.
Conclusions
Hysterosalpingography is not sufficiently accurate, with regard to specificity or sensitivity, for screening pathologies of the endometrial cavity in infertile patients. Hysteroscopy should be performed in all patients before IVF and artificial insemination.
As a widely-applied clinical therapy for infertility and sterility, A RT has its own merits compared to other techniques and operations; however, the outcome of A RT is influenced by various factors ranging from age, endometrial receptivity, reproductive system condition (e.g. uterus, fallopian tube and pelvic factors, etc.), immune system and so on. From our clinical experience and the literatures reviewd, it is strongly recommended that the situation of every infertile couple be evaluated thoroughly before applying therapy. Age More and more attention was paid to the relationship between advanced female repro-ductive age (or old age) and A RT. The decrease of female fecundity began in the 30's, becoming more pronounced after 40. There is an approximately 50% decrease in the fecun-dity rate of woman attempting pregnancy at the age of 40 or over compared with younger women, and a twofold to threefold increase in the rate of spontaneous abortions. In addition to the pelvic organ diseases and endocrine disorders, the main cause of A RT failure is the aging of oocyte and granulosa cell, and then is the reduction of endometrium receptivity, which may be related to the blood flow of uterus [ 1 ] . Ovarian reserve tests, e.g. the basal level of FSH, E2, and inhibin, FSH/LH ratio and real-time stimulation test (e.g. CC, GnH or GnRH test), should be done in women who are more than 35 years old; and transvaginal sonography (TVS) should also be done to evaluate the ovarian volume, follicular development, blood flow, etc. Some authors suggest that the basal level of FSH is more effective in prospecting the rate of cycle canceling and pregnancy in IVF program than age [ 2 ] . Increasing age of patient is associated with poor ovarian response, as represented by smaller ovarian volume, lower antral follicle count, and poor stromal vascularity. Three-dimensional power Doppler ultrasonography can help to individualize IVF in patients regard-less of age [ 3 ] .
The place of surgery in the management of an infertile couple is still under debate. Good pregnancy outcomes in assisted reproductive technologies have led to a decrease in surgical indications. In this evidence based review, we updated our data of high powered articles in order to establish national guidelines for clinical practice about the role and benefits of surgery in principal etiologies of female infertility.
Copyright © 2010 Elsevier Masson SAS. All rights reserved.
To evaluate the importance of subjecting the patient to an outpatient (office) hysteroscopy (OH) before assisted reproductive techniques (ART) and patient compliance, possible side effects, and complications of the procedure.
Comparative observational cross-sectional study.
University hospital.
One hundred fifty-two patients attending the outpatient infertility clinic for pre-ART (IVF/intracytoplasmic sperm injection [ICSI]-ET) investigations, with normal uterine findings on hysterosalpingography (HSG).
Transvaginal sonography (TVS) and OH (using a rigid, 30-degree, 4-mm hysteroscope) by the vaginoscopic "no touch" technique.
Diagnostic value and compliance of OH.
The procedure was successful in 145 patients (95.4%); 51 of them (35.2%) had previous ART failures. Abnormal hysteroscopic findings were observed in 48 women (33.1%), in which endometrial polyp, submucous myoma, and intrauterine adhesions were the most common findings. The TVS was specific (100%) but not sensitive (41.7%) compared with OH. Abnormal hysteroscopic findings were significantly higher in patients with previous ART failure(s). The procedure was acceptable in almost all patients with no reported complications.
The OH should be part of the infertility workup before ART even in patients with normal HSG and/or TVS. This is especially relevant in cases with prior failed ART cycles.
Recurrent implantation failure (RlF) may be due to unrecognized uterine pathology. Hysterosalpingography, transvaginal ultrasonography, saline infusion sonography and hysteroscopy are the tools to assess the inner architecture of the uterus. Hysteroscopy is considered to be the gold standard; however, the validity of hysteroscopy may be limited in the diagnosis of endometritis and endometrial hyperplasia. The frequencies of unrecognized uterine pathology revealed by hysteroscopy are 18-50% and 40-43% in patients undergoing IVF with or without RlF, respectively. Endometrial polyps may be associated with increased miscarriage rates. Implantation rates are decreased in patients with submucous or intramural fibroids with distorted uterine cavity. There is controversy on the impact of uterine septum less than 1 cm length on pregnancy outcome in IVF cycles. There is paucity of data on the role of hysteroscopy in failed IVF cycles. In the available two randomized controlled trials, pregnancy rates appear to be increased when hysteroscopy is performed; however within the hysteroscopy group, pregnancy rates are comparable among the normal or surgically corrected subgroups. Further studies are warranted to delineate the role of hysteroscopy in patients with failed IVF cycle(s). This review aims to evaluate the validity of office hysteroscopy in failed IVF cycles.
Hysteroscopy is an excellent additional instrument for evaluating the uterine characteristics in infertile women. This article reviews the two main indications for hysteroscopy in infertile patients who are candidates for assisted reproductive techniques: (1) to evaluate the cervix and uterine cavity and (2) rule out any pathology or lesions that could have been missed by hysterosalpingography. Hysteroscopy has been proposed as an alternative method to traditional transabdominal transfer of gamete or embryo to the tube.
Diagnostic, panoramic hysteroscopy can be performed in an office setting with small discomfort to the patient. The procedure enables the physician to search for organic intrauterine abnormalities and to select the proper form of therapy based on the observations. Often no pathology is seen and further surgical interventions are not needed. This operation currently represents the state of the art for investigation of the endometrial cavity. In the future it will become the standard of care as the first step for evaluation of causes of abnormal uterine bleeding in selected patients.
To compare office hysteroscopy with suction biopsy versus the hospital procedure with respect to clinical outcomes, success rates, and cost.
Retrospective review of outpatient and inpatient records for all attempted office hysteroscopies with suction biopsy from September 1991 to June 1995, and all hospital diagnostic hysteroscopies with dilatation curettage from January 1993 to June 1994.
Multispeciality office group practice and a university-affiliated private hospital.
Four hundred seventy-three women who had office hysteroscopy with suction biopsy and 95 who had hospital diagnostic hysteroscopy with dilatation curettage.
The procedures were performed by 13 gynecologists who had no experience with office hysteroscopy.
A cost analysis was completed by obtaining hospital and anesthesia charges for the hospital procedures and comparing them with office, instrument repair, and capital equipment costs. Gynecologists' professional fees were excluded from the analysis since they were the same in both settings. The overall failure rates to complete office and hospital hysteroscopies were 7.2% and 3.1%, respectively. Abnormal uterine bleeding was the indication in 89% of office and 96% of hospital procedures. Office hysteroscopy in these women revealed an abnormality in 40.1% of office versus 38.5% of hospital procedures. Histology revealed insufficient tissue for diagnosis in 3.4% office and 22.1% hospital procedures. The minor complication rate for office hysteroscopy was 1.9% and for hospital hysteroscopy 4.2%. There were no major complications in either group. The mean charges, excluding professional fees, for the hospital were 62 for office hysteroscopy.
Office hysteroscopy has a high success rate and a low complication rate even when performed by a group of gynecologists with limited experience in the procedure. Because of its lower cost and greater diagnostic accuracy, office hysteroscopy with suction biopsy should be the method of choice for evaluating gynecologic conditions such as abnormal bleeding.
Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.
Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF-embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.
Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).
Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the "take-home baby" rate.
To compare transvaginal sonography with hysteroscopy for the evaluation of intrauterine disorders.
Clinical study.
Academic research environment.
Patients who were undergoing initial evaluation for primary or secondary infertility or investigation after three failed IVF attempts.
Transvaginal sonography was performed, followed by hysteroscopy, between January 1998 and April 1999. The endometrial findings at sonography were compared with those at hysteroscopy, which served as the gold standard. The characteristic sonographic features of intrauterine adhesions were defined.
Intrauterine adhesions, endometrial polyps.
The sensitivity, specificity, and positive and negative predictive values for transvaginal sonography in detecting abnormal uterine cavities were 100%, 96.3%, 91.3%, and 100%, respectively. The corresponding values for the specific diagnoses of intrauterine adhesions and endometrial polyps were 80%, 100%, 100%, and 97%, and 71.4%, 100%, 100%, and 97.1%, respectively. On transvaginal sonography, intrauterine adhesions appeared as hyperechoic endometrial foci and were differentiated from endometrial polyps by their irregular shape and more precise localization. The performance of transvaginal sonography at midcycle (three-layer endometrium) rather than after menstrual cessation (endometrial thickness <3 mm) enabled better imaging of small intrauterine adhesions.
A regular myometrial-endometrial interface and homogeneous endometrial structure on transvaginal sonography congruent with the phase of the menstrual cycle indicated a normal endometrium and precluded the need for diagnostic hysteroscopy. Transvaginal sonography may be used as the initial diagnostic procedure to select patients for hysteroscopy.
To evaluate the effectiveness of modified hysterosalpingography using <3 mL amount of contrast medium followed by injection of saline to minimize the adverse effects associated with the procedure.
For modified hysterosalpingography, 1-2 mL of water-soluble contrast medium were injected to visualize the uterine cavity, followed by injection of 10 mL of saline to check tubal patency and spillage. A control group of patients underwent hysterosalpingography with undiluted contrast medium.
Teaching hospital.
Seventy-eight infertile women [study (n = 40)/control (n = 38) groups].
Modified and standard hysterosalpingography.
Assessment of uterine cavity, tubal patency, and sensation of pain during modified hysterosalpingography was compared with that during standard hysterosalpingography.
Uterine cavity and tubal patency were properly visualized during modified hysterosalpingography. Saline pushed the contrast medium successfully from the uterine cavity through the open fallopian tubes and into the pelvic cavity. The study group reported significantly less pain than did the control group. Between-group differences were statistically significant when pain perception (no pain vs. minimal pain vs. severe pain; no pain vs. any kind of pain) was analyzed by type of adnexal pathology (bilateral passage or unilateral passage).
Modified hysterosalpingography was sufficient to diagnose tubal and pelvic mechanical factors. The procedure was associated with a significant reduction in self-reported pain and no medical complications.
To evaluate the use of transvaginal sonography for the detection of pelvic adhesions by using clear free fluid in the pouch of Douglas found after ovum pickup.
A prospective clinical study was performed in an infertility unit of an academic research facility. Sonography was performed in 50 women with infertility 3 days after ovum pickup, and the visceral peritoneum of the uterus, the ovaries, and the fallopian tubes was scanned for possible pelvic adhesions.
The serosal surfaces of the uterus, ovaries, and fallopian tubes were successfully observed for the presence of adhesions in 86%, 68%, and 20% of the patients, respectively. Improved visualization was associated with an increased amount of pelvic fluid for the uterus (P = .01) but not for the ovaries and fallopian tubes. The amount of fluid in the pelvis correlated with an increased number of retrieved oocytes (P = .07) and a decreased need for manual manipulation to achieve proper imaging of the uterus (P = .001).
Transvaginal sonography performed in the presence of fluid in the pelvis may show adhesions mainly attached to the uterus and ovaries. Assessment of possible mechanical factors is important in planning treatment of patients with infertility.
The study was conducted to evaluate if the diagnosis and treatment of intrauterine lesions with office hysteroscopy is of value in improving the pregnancy outcome in patients with recurrent in-vitro fertilization and embryo transfer failure. Four hundred and twenty-one patients who had undergone two or more failed IVF-embryo transfer cycles were prospectively randomized into two groups. Group I (n = 211) did not have office hysteroscopic evaluation, Group II (n = 210) had office hysteroscopy. The patients who had normal hysteroscopic findings were included in Group IIa (n = 154) and patients who had abnormal hysteroscopic findings were included in Group IIb (n = 56). Intrauterine lesions diagnosed were operated during the office procedure. Fifty-six (26%) patients in Group II had intrauterine pathologies and the treatment was performed at the same time. No difference existed in the mean number of oocyte retrieved, fertilization rate, number of embryos transferred or first trimester abortion rates among the patients in groups. Clinical pregnancy rates in Group I, Group IIa and Group IIb were 21.6%, 32.5% and 30.4% respectively. There was a significant difference in the clinical pregnancy rates between patients in Group I and Group IIa (21.6% and 32.5%, P = 0.044, respectively) and Group I and Group IIb (21.6% and 30.4%, P = 0.044, respectively). There was no significant difference in the clinical pregnancy rate of patients in Groups IIa and IIb. Patients with normal hysterosalpingography but recurrent IVF-embryo transfer failure should be evaluated prior to commencing IVF-embryo transfer cycle to improve the clinical pregnancy rate.
Objective: To report a case of ongoing pregnancy in a woman who underwent hysteroscopy during the implantation phase. Design: Case report. Setting: A university hospital. Patient(s): A 34-year-old woman with unexplained infertility who was scheduled for IVF. Intervention(s): Office hysteroscopy. Main Outcome Measure(s): Hysteroscopy during early pregnancy. Result(s): An ongoing pregnancy after hysteroscopy during the implantation phase. Conclusion(s): The risk of a properly performed hysteroscopy in the implantation phase of an unrecognized pregnancy may be less than expected. (C)2005 by American Society for Reproductive Medicine.
To determine current practice in the management of recurrent in vitro fertilisation (IVF) treatment failure in licensed UK infertility centres.
National postal questionnaire study and literature review.
University Hospital, Centre for Reproductive Medicine, Coventry, UK.
Human Fertilisation and Embryology Authority licensed centres providing IVF/intracytoplasmic sperm injection (ICSI) in the UK (n = 79).
A survey was designed that sought to determine how recurrent treatment failure was defined and which, if any, investigations were initiated. Furthermore, we asked which therapeutic options were subsequently recommended.
Definition of recurrent treatment failure. Investigations undertaken. Clinical or embryology changes recommended following recurrent treatment failure.
The response rate was 82%. The most common definition was three unsuccessful IVF cycles (range 2-6). Nineteen percent included frozen embryo replacements (FERs) in this figure. Anticardiolipin antibodies and lupus anticoagulant were the most frequent investigations suggested, followed by hysteroscopy and karyotype. A majority of centres would use a different treatment strategy in a subsequent cycle with blastocyst culture and assisted hatching being most popular.
The results of this survey suggest that there is considerable variation in the approach to investigation and management of recurrent IVF treatment failure in the UK, although in some areas (e.g. the definition) there was broad concordance. Not all of these approaches are evidence based.
The aim of this study was to compare traditional hysteroscopy with mini-hysteroscopy in terms of compliance, side effects and diagnostic efficacy.
We prospectively considered 950 female candidates for an IVF programme. All women underwent outpatient hysteroscopy; in 602 cases (Group A) a mini-hysteroscope was employed; in 348 women (Group B) a 5-mm hysteroscope was adopted.
Cavity findings were similar in both groups. Endometrial polyps and uterine septum seem to be more frequent in our infertile patients than in the general population. No significant differences in terms of side effects were found between the groups. Mean visual analogue pain scale score was significantly lower in the patients of Group A than in those of Group B (p<0.001).
Office mini-hysteroscopy is a very effective diagnostic tool in an infertility work-up and is more widely accepted than traditional hysteroscopy. Routine use of the technique should be considered.
We evaluated the uterine cavity by sonohysterography (SHG) in patients with recurrent failed IVF-embryo transfer despite transfer of good quality embryos, compared with other diagnostic methods. We found that SHG is highly valuable and should be applied routinely as a first-line, office-based diagnostic tool in such cases.
A systematic review of studies evaluating the influence of outpatient (office) hysteroscopy on the outcome of the subsequent IVF cycle was conducted. MEDLINE, EMBASE, the Cochrane Library, National Research Register, ISI Conference Proceedings, ISRCTN Register and Meta-register were searched for randomized controlled trials (up to July 2007). All trials comparing the outcome of IVF treatment performed in patients who had outpatient hysteroscopy in the cycle preceding their IVF treatment with a control group in which hysteroscopy was not performed were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. Study authors were contacted for additional information. The main outcome measure was pregnancy rate. In total, 1691 participants were included in two randomized (n = 941) and three non-randomized controlled studies (n = 750). The quality of the studies was variable. Meta-analyses of the results of five studies showed evidence of benefit from outpatient hysteroscopy in improving the pregnancy rate in the subsequent IVF cycle (pooled relative risk = 1.75, 95% CI 1.51-2.03). The evidence from randomized trials was consistent with that from non-randomized controlled studies. Future robust randomized trials comparing outpatient hysteroscopy or mini-hysteroscopy with no intervention before IVF treatment would be a useful addition to further guide clinical practice.
In a program of human in vitro fertilization (IVF), the results of 204 attempted intracervical embryo transfers (ETs), using a variety of catheters in three trials over 18 months, have been analyzed for the ease of transfer and pregnancy rate. In nulliparous patients, transfers were more difficult than in multiparous patients; and a closed-end Teflon catheter was found to be more easily passed through the smaller cervical canal than an open-end catheter. The overall pregnancy rate was 17% (March 1980 to August 1981) and was not related to catheter type, although when chemical pregnancies were excluded, it was found that transfers using open-end catheters were more successful. The transfer procedure developed finally for routine use incorporates a consideration of these results.
Two hundred eighty-four hysteroscopies were performed in 312 (91%) candidates for in vitro fertilization and embryo transfer (IVF-ET) who were divided into two groups. Group I consisted of elderly women over 40 years, and group II of women below this age. Although visualization revealed uterine abnormalities in 29.9% of all patients, abnormal findings were significantly increased in the former group in comparison to the latter (P<0.001). This difference was attributed mainly to uterine rather than cervical pathology. Furthermore, in elderly women agerelated uterine pathology such as submucous myomata, endometrial hyperplasia, and polyps were more prominent, while in younger patients other uterine lesions such as adhesions and tubal ostia occlusion were more common. Moreover, treatment prior to IVF-ET resulted in 7 clinical pregnancies (8.9%) in group I and in 41 clinical pregnancies (19.9%) in group II, all of which failed in one to three cycles previously. It seems that hysteroscopic evaluation may reduce the IVF-ET failure rate due to intrauterine abnormalities in elderly as well as young patients, thus it becomes an absolute prerequisite for all patients scheduled for an IVF program.
Hysteroscopic treatment was provided for 122 of 139 women complaining of primary or secondary infertility. Hysteroscopy revealed intrauterine lesions and the following treatments were carried out: lysis of intrauterine adhesions (61), removal of large endometrial polyps (47), removal of submucous leiomyomas (4), removal of embedded fragmented IUD (4), division of uterine septa (3) and treatment of other unusual conditions (3). The reproductive outcome included 46 term pregnancies, 28 following the division of intrauterine adhesions, 11 after the removal of endometrial polyps, 2 after correction of a septate uterus, one after removal of a pedunculated intrauterine leiomyoma, and 4 after removal of different foreign bodies. There were 8 spontaneous first trimester abortions, and 1 ectopic pregnancy. Removal of the lesion and restoration of a symmetric uterine cavity was successful in 119 patients; only 3 failures occurred, in patients with severe Asherman's syndrome.
Hysteroscopy has been recommended as a procedure to replace hysterosalpingography (HSG), but the 2 procedures should be considered complementary rather than competing techniques. HSG is a relatively inexpensive procedure that provides important information about the endocervical canal, the region of the internal os, the uterine cavity, and the entire course of the fallopian tubes. The latter information is invaluable for the infertile patient. HSG may reveal information that would alter the patient's management. A comparison of HSG and hysteroscopy is presented in a table which clearly demonstrates the advantages of hysteroscopy over HSG. The hysteroscope is an important instrument for the diagnosis of some causes of infertility, yet its primary value lies in treatment. Intrauterine diagnosis and surgery for the infertile patient should be confined to 6 procedures. Of these, the use of hysteroscopy for both the diagnosis and treatment of intrauterine adhesions has been shown to be mandatory. Less data are available to support the use of hysteroscopy to resect submucous myomas and even less information is available regarding its use for resection of a uterine septum. The manifestations of intrauterine adhesions include menstrual aberrations, pregnancy wastage, intrauterine fetal demise and errors of placental implantation, and infertility. Prior to the advent of hysteroscopy, the diagnosis of intrauterine adhesions depended upon historic criteria, physical findings, and laboratory data, and the treatment consisted of an attempt to bluntly disrupt the adhesions by using a uterine sound or small curette. Early hysteroscopic efforts toward treatment of intrauterine adhesions led to an overall pregnancy rate of about 40% and fewer than 60% of these patients delivered at term. A table presents data on the author's 1st 67 patients who underwent treatment for intrauterine adhesions. The patients ranged in age from 19-41 years. 60 had been pregnant on 1 or more occasions, but only 31 had delivered an infant. The most common antecedent factor in this group of patients was curettage for elective pregnancy termination. The most common menstrual pattern was that of amenorrhea. 1 great value of hysteroscopy is that it permits the operating surgeon to classify the extent of the disease. Treatment consisted of visualization of the adhesions under direct visualization. Hysteroscopy was performed in the follicular phase for those patients who were menstruating. All adhesions were lysed under direct vision. An IUD was inserted into the cavity. The patient was initially given conjugated estrogens for 60 consecutive days. After withdrawal bleeding, the IUD was removed. The patient's uterus was reinvestigated after the 1st spontaneous menstrual period. 75% of patients who wanted to conceive and in whom no other infertility factors could be identified have done so.
Endometrial and tubal causes of female infertility have been sought with the use of endometrial biopsy, the Rubin test, hysterosalpingography, and laparoscopy. Hysteroscopy, used as an adjunct to these methods, can increase their effectiveness in evaluating uterine or tubal factors that may account directly or indirectly for reproductive failure. Hysteroscopy was included in the diagnostic evaluation of 142 patients with a diagnosis of primary or secondary infertility. In 62%, visually recognizable abnormalities were found, such as intrauterine adhesions, endometrial polyps, submucous leiomyomas, and uterine septa, that could explain the infertility. In 31.7% of 63 patients who had an abnormal hysterosalpingogram, hysteroscopy demonstrated a normal uterine cavity. Even though hysteroscopy is useful as a diagnostic and therapeutic adjunct to traditional methods for evaluation of uterine factors in infertility, it does not replace or exclude them. Rather, it complements the procedures, particularly when abnormal hysterosalpingograms have been obtained, when intrauterine adhesions are suspected, or when there is abnormal uterine bleeding. Performed concomitantly with laparoscopy, hysteroscopy becomes the most effective technique for evaluation of the uterine and tubal conditions that may play a role in female infertility.