What is Hysteroscopy?

In the past 20 years, numerous factors that make it difficult to conceive naturally have been addressed. Among these, intrauterine pathologies can play a significant role. Various treatments have been proposed to overcome infertility caused by intrauterine pathologies.

Hysteroscopy is currently considered the gold standard method for both evaluating and managing intrauterine factors. Compared to vaginal ultrasound and hysterosalpingography (HSG), hysteroscopy allows for more accurate detection of intrauterine abnormalities and, more importantly, enables the treatment of identified pathologies in the same session.

In summary, hysteroscopy involves inserting a camera into the uterus to examine it and treat any identified pathologies during the same procedure.

What are the most common uses of Hysteroscopy?

Suspected intrauterine lesions

Abnormal uterine bleeding

Abnormal thickening of the uterine lining

Postmenopausal bleeding

Infertility

Congenital uterine anomalies

Removal of foreign bodies

What is the importance of Hysteroscopy in infertility diagnosis and treatment?

Hysteroscopy emerges as the gold standard method for diagnosing and treating intrauterine pathologies, which are present in about 25% of infertile women. Intrauterine pathologies can hinder natural conception or conception through IVF or insemination methods.

Even in the presence of small intrauterine pathologies representing only 2-3% of the causes of infertility, their treatment with hysteroscopy can help improve embryo implantation and pregnancy rates.

However, the treatment of intrauterine pathologies does not always mean that fertility will be fully restored.

Intrauterine polyps and intrauterine fibroids are pathologies commonly encountered not only in cases of infertility but also in women experiencing abnormal uterine bleeding without fertility problems. The most common uterine cavity anomaly is polyps. Intrauterine polyps can be found in 1% to 41% of infertile women. These benign, often pedunculated structures extend into the uterine cavity and have their own vascular support. It is believed that intrauterine polyps hinder embryo implantation and negatively affect fertility. Current evidence supports the removal of intrauterine polyps by hysteroscopy before IVF to increase fertility. 

Fibroids are excessive growths originating from the muscular layer of the uterine cavity. Fibroids are found in 2.4% of infertile women, and submucosal fibroids located in the uterine lining deform the uterine cavity, leading to decreased fertility. Therefore, submucosal fibroids should be removed when detected in infertile patients. Fibroids in the uterine muscle layer should also be removed, regardless of their size or the presence of symptoms, especially if they significantly affect the uterine lining.

Another cause of infertility associated with abnormal uterine bleeding is isthmocele or uterine scar defects following cesarean section. These can be classified as first, second, and third degree based on their size. It is reported that hysteroscopic treatment of isthmocele is associated with increased pregnancy rates.

Intrauterine adhesions associated with Asherman’s syndrome sometimes occur after uterine surgeries or due to damage from intrauterine infections. Intrauterine adhesions are found in 0.3% to 14% of infertile women. These adhesions, sometimes detected as thickening of the uterine lining on ultrasound, can be responsible for infertility and recurrent pregnancy loss. In this context, hysteroscopy is accepted as the gold standard for both diagnosis and treatment.

In fact, the frequency of congenital uterine anomalies is higher in women with a history of recurrent miscarriage or infertility compared to those without such a history. Among these anomalies, septate uterus is the most common structural anomaly associated with the highest failure rates in reproduction. Between 1% and 3.6% of women with unexplained infertility have a septum in the uterus. Opening the septum with hysteroscopy increases the live birth rate by 80%.

Should hysteroscopy be applied before IVF?

– In clinical practice, hysteroscopy before IVF is a commonly used method in most patients, including those with normal uterine imaging on vaginal ultrasound and/or hysterosalpingography. This is because there may be uterine pathology that could negatively affect the success of fertility treatment and may have been missed by other methods.

– Performing hysteroscopy before the next IVF treatment in patients with difficult embryo transfers allows for direct examination of the uterine canal to facilitate embryo transfer.

– Mechanical damage to the uterus, or scratching the uterus, can be performed with hysteroscopy to identify factors encoding genes necessary for embryo implantation and thus increase uterine receptivity.

– Hysteroscopy is also recommended after two or more unsuccessful IVF attempts.

What is the difference between diagnostic hysteroscopy and operative hysteroscopy?

If the procedure is aimed solely at evaluating the uterine cavity, it is called diagnostic hysteroscopy. If the observed pathology requires further treatment, the procedure is called operative hysteroscopy. In daily practice, diagnostic hysteroscopy confirming the presence of pathology will be followed by operative hysteroscopy in a patient with accompanying complaints.

What are the advantages of diagnostic hysteroscopy?

Diagnostic hysteroscopy offers many potential benefits, including ease for both the patient and the physician, avoidance of general anesthesia, higher patient satisfaction, faster recovery, and cost-effectiveness. Factors that may challenge the feasibility of diagnostic hysteroscopy include large intrauterine pathologies, patient anxiety, and the skill and expertise of the physician. It is best for the physician evaluating the patient to decide which method to use.

Preparation for Hysteroscopy

Preparation for hysteroscopy involves preoperative assessment and personalized testing based on the patient’s needs. If there are underlying medical conditions that increase the risk of surgery, advanced tests should be conducted for preoperative preparation.

Hysteroscopy can be performed in postmenopausal women at any time. For women of reproductive age, hysteroscopy is preferred in the week following the end of menstruation. The use of misoprostol for cervical preparation is a decision made by the physician based on the individual patient.

How is Hysteroscopy Performed?

Assessing the uterine cavity appears to be a fundamental step in the investigation of all subfertile women because it is assumed to be important for the attachment of the human embryo, known as the blastocyst, to the uterine cavity and its inner layer, the endometrium. However, the complex mechanisms leading to successful attachment are still not fully understood.

Hysteroscopy allows for direct visualization of the uterine cavity using a rigid, semi-rigid, or flexible endoscope. A hysteroscope consists of a rigid telescope with an objective lens that can be 0° straight or angled to provide an anteverted view, allowing for direct visualization. Advances in fiberoptic technology have led to miniaturization of telescopes without compromising image quality. The total working diameter of modern diagnostic hysteroscopes typically ranges from 2.5 mm to 4.0 mm. Operative hysteroscopy requires continuous fluid circulation through an inlet and outlet channel to ensure adequate visualization.

While diagnostic hysteroscopy can be performed in a clinical setting using local anesthesia and a fluid distension medium, more complex procedures, such as operative hysteroscopy, are usually performed as day surgery under general anesthesia. Operative hysteroscopy requires complex instrument setup, specialized training for the surgeon, and proper knowledge and management of complications.

Complications of Hysteroscopy

Diagnostic hysteroscopy has a significantly lower complication rate compared to operative hysteroscopy.

Complications such as uterine perforation, excessive fluid overload, and emboli (blood clots) during surgery are very rare occurrences. Your doctor will provide the necessary medical treatment and follow-up if such a complication arises. What matters most is recognizing the complication during surgery and taking the necessary precautions and planning for treatment. This will be done with an experienced obstetrician-gynecologist.

How should patient follow-up be after hysteroscopy?

Mild bleeding is normal after hysteroscopy since there is manipulation of tissues inside the uterus during the procedure. However, if there is excessive bleeding or prolonged bleeding, it’s important to consult a doctor. Therefore, using pads for a few days after the procedure is important. The amount and duration of bleeding can vary depending on the individual’s body and the intervention performed during the procedure. It is recommended to avoid heavy exercise for a few days after the procedure. Additionally, postponing sexual intercourse for a while will reduce the risk of bleeding and infection.

Since there is intervention in the uterine cavity during hysteroscopy, it may carry a risk of infection. However, don’t worry, there are measures you can take to minimize the risk of infection. Firstly, you must strictly follow the instructions given by your doctor. These instructions are important for hygienic healing after the procedure. For example, your doctor may recommend antibiotics or antiseptic solutions to clean the vaginal area after the procedure. Using these will help reduce the risk of infection. Secondly, it is recommended to avoid sexual intercourse. Also, avoid using tampons, as this can increase the risk of infection.

If you experience symptoms of infection after the procedure, you should consult your doctor immediately. Symptoms of infection may include fever, severe abdominal pain, foul-smelling discharge, or burning sensation during urination. These symptoms indicate a possible infection and may require prompt treatment.

Recovery Process After Hysteroscopy

After hysteroscopy, returning to normal daily activities is usually possible immediately. However, it’s important to follow the recovery process by adhering to the instructions provided by the doctor.

The recovery process after hysteroscopy can vary from person to person. Most patients tolerate diagnostic and operative hysteroscopy well and can be discharged from the recovery unit or outpatient clinic immediately after the procedure is completed. Typically, there may be mild bleeding after the procedure. This is normal and usually resolves spontaneously within a few days. However, if there are symptoms such as excessive bleeding, severe abdominal pain, or fever, it is important to consult a doctor immediately.

It is important to follow the instructions given by the doctor to monitor the recovery process. These instructions usually include the use of pain relievers, hygienic healing, and avoiding sexual activity. Carefully following your doctor’s recommendations is important for a quick and healthy recovery process.

Post-hysteroscopy follow-up appointments are also important. Your doctor will schedule appointments for post-procedure checks. During these check-ups, your uterine condition and healing process will be evaluated. If there are any problems or complications, your doctor will recommend necessary treatments.

In conclusion, returning to normal daily activities after hysteroscopy is usually possible immediately. However, it is important to follow the instructions provided by the doctor to monitor the recovery process. Additionally, it is necessary to attend post-procedure follow-up appointments and carefully follow your doctor’s recommendations for healthy healing.