The Hysteroscopy Encyclopedia

hsc4

Hysteroscopy is becomig an increasingly important tool in the evaluation of the infertile patient (Valle & Sciarra,1979). Hysteroscopy in the evaluation of infertility patients has revealed uterine abnormalities at reported rates that vary from 19-62% (Lindemann,1971). The clinical significance of these findings remains to be completely evaluated, but relevant intrauterine conditions and their impact on infertility are known. (Dunn,1994).

    Hysteroscopy enables inspection of the cervical canal and the uterine cavity, and also the evaluation of the tubal ostium and the proximal intramural segment of the fallopian tube. Hysteroscopy is the most accurate method of diagnosing endometrial polypi, submucous fibroids and synechiae (Mencaglia & Guidetti,1993).
    
    However, hysteroscopy is unreliable in the assessment of tubal patency, and the intramural and isthmic segments of the tubes need to be evaluated by hysterosalpingography and laparoscopy (Mencaglia & Guidetti, 1993).

    In case of infertile patient with uterine anomaly, a complete infertility investigation is mandatory before surgical treatment for a uterine anomaly, so that other infertility factors can be ruled out. (March,1989).

    A study was done,1985, by Stillman & Asarkof, to detect association between Mullerian duct malformations and Asherman syndrome in infertile patients. Mullerian anomalies were found in 8% and Asherman syndrome in 4.8% of 537 infertile women undergoing HSG and hysteroscopy.

    Among the 43 patients with mullerian anomalies and the 26 with Asherman syndrome, seven had both mullerian anomalies and IUA(16 and 29% respectively). This association was highly significant, especially for those patients with a septate uterus.Secondary infertility was found in 44% of the patients with mullerian malformations versus 81% of those with Asherman syndrome.

    The significance of thin filmy adhesions in the uterine cavity (grade I) is not known although such adhesions seem to be a relatively frequent finding in eumenorrhoeic infertility patient (Taylor et al., 1981).

    Uterine myomas can be found in a variety of locations, those protruding into the uterine humen are a common cause for abnormal uterine bleeding and my lead to infertility. Submucous myomas cause infertility by a variety of mechanisms related to sperm migration and embryo implantation.

    The HSG appearance of submucous myomas is of a persistent, usually smooth, filling defect. The HSG suspicion should be confirmed by hysteroscopy. The hysteroscopic diagnosis of a submucous myoma is easy. The hemispheric protrusion into the uterine cavity is regular, smooth, firm and covered with atrophic endometrium and dilated vessels. The pedunculated fibroid is less typical and may resemble an endometrial polyp. The purely intramural myoma is difficult to detect, as the distortion of the endometrial cavity is its only sign and is not hysteroscopically obvious (March,1989).

    Following the acceptance of hysteroscopy as a valid and useful diagnostic method, selected surgical techniques have been designed to provide a theraputic effect. With intrauterine pathology directly connected with infertility, there are advantages in using the endoscopic surgical technique, and many traditional surgical approaches can be replaced by operative hysteroscopy. (Mencaglia & Guidetti, 1993).

    Intrauterine diagnosis and surgery for the infertile patient should be restricted for the following six procedures:

• lysis of intrauterine adhesions
• resection of a septum
• resection of a myoma
• resection of a polyp
• cannulation of tubal ostia
• removal of foreign bodies.

    The use of hysteroscopy for both diagnosis and treatment of intrauterine adhesions was the first procedure as being mandatory. Simultaneous hysteroscopy and laparoscopy to treat the septate uterus has made the Tompkins and Jones procedures obsolete. Data are now available to support the use of hysteroscopy in resection of submucous myoma.(March,1989).

    Polypi  probably do not cause infertility or pregnancy loss but often can not be diagnosed with certainty by HSG, and hysteroscopy allows complete removal with less endometrial trauma than does curettage (March,1989)

    The skill of the hysteroscopist in using the equipment and the distension medium and hemostasis methods used are important factors in ensuring the advantages of hysteroscopy approach and therapy (Mencaglia & Guidetti, 1993).

Filmy Intrauterine adhesions in eumenorrheic females

    The incidence of filmy intrauterine adhesions in an infertile eumenorrheic patient was studied by Taylor et al., 1981. Comparing it with an apparently fertile eumenorrhoeic females, it was found in 48 of 228 eumenorrhoic infertile women (12.8 %) . However, further studies are required to determine if removal of such adhesions may result in improved reproductive performance.
(Talyor et al.,1981).

    Filmy intrauterine adhesions may cause difficulty in transvaginal tubal catheterisation if they are located in the cornual angle of the uterine cavity. Usually these fibrotic filmy adhesions are not always detected by hysterosalpingography. These avascular adhesions are one explanation for the false-negative findings in HSG when compared with hysteroscopy.  In this case the first step is to restore the shape of the uterine cavity before tubal catheterisation is done (Eckstein et al.,1993).