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Role of Hysteroscopy in Infertility

- 8 min read
written by Shield Connect

Infertility is becoming more common, and researchers are working hard to develop and refine diagnostic and therapeutic approaches for patients. Many specialists now agree that a thorough infertility workup should include a uterine cavity examination.

Infertility is becoming more common, and researchers are working hard to develop and refine diagnostic and therapeutic approaches for patients. Many specialists now agree that a thorough infertility workup should include a uterine cavity examination. Hysteroscopy is the gold standard for examining the uterine cavity, and thanks to advancements in endoscopic technology, it can now be done consistently and safely in proper set up1.In comparison to other blind or indirect diagnostic procedures, having a direct view of the uterine cavity has a substantial advantage. Although hysterosalpingography (HSG) is as reliable as hysteroscopy in diagnosing normal and abnormal cavities, hysteroscopy is more accurate in revealing the nature of intrauterine filling abnormalities. The purpose of hysteroscopy in infertility investigations is to detect any intrauterine alterations that may interfere with the concept us’s implantation or growth, or both, and to compare the effectiveness of various treatment options in restoring a normal endometrial environment2.

Hysteroscopy for infertility (indications):

  1. Abnormal hysterosalpingogram
  2. Abnormal uterine bleeding
  3. Suspected intrauterine pathology
  4. Uterine anomalies
  5. Unexplained infertility
  6. Recurrent Pregnancy Loss

Endometrial scratching appears to improve the possibility of a pregnancy for couples seeking to conceive spontaneously or with Intrauterine Insemination (IUI), according to the European Society of Human Reproduction and Embryology (ESHRE) 3.Uterine factors are discovered in just 2 to 3 percent of infertile women, although intrauterine lesions (40–50 percent) are far more common. These lesions can affect both spontaneous and assisted reproductive fertility, lowering conception rates4.In women with unexplained infertility prior to IVF or IUI or ICSI, a Cochrane review evaluated the effects of surgical hysteroscopy on pregnancy rate versus no intervention. Three more systematic studies looked at the impact of diagnostic and/or operational hysteroscopy on reproductive outcomes in women who were undergoing their first or second IVF/ICSI cycle and the result was very promising5,6.

Indication of operative hysteroscopy for reproductive failure

  • Polyp
  • Misplaced or embedded IUD
  • Intrauterine adhesion
  • Uterine septa
  • Tubal canulation & Falloposcopy
  • Submucous leiomyoma

Common problems


The processes through which submucous leiomyomas influence fertility are unknown. The ability of fibroids to interfere with fertility is determined largely by its location. Regardless of the size or existence of symptoms, submucous fibroids interfere with conception and should be removed in infertile patients 5. When the uterine cavity contour is normal, hysteroscopy looks to be unneeded. When HSG reveals a uterine cavity filling defect, sonohysterography (SIS) or office hysteroscopy can more clearly characterise the location and attachment of the lesion, as well as assess whether a submucous myoma is amenable to hysteroscopic myomectomy. Research study suggested that due to decreased embryo implantation, submucosal fibroids exhibited the highest connection with lower ongoing pregnancy rates (odds ratio, 0.5; 95 percent confidence interval, 0.3–0.8). Despite the small number of patients analysed, there is significant evidence in favour of hysteroscopic myomectomy in women before undergoing ART. Hysteroscopic myomectomy is suggested for intracavitary and submucous myomas with at least 50% of their volume within the uterine cavity, according to the ASRM (2008) 7. Myomectomy should only be considered in infertile women and those who have experienced recurrent pregnancy loss following a thorough review.

Mullerian Anomalies

Because of the many diagnostic criteria used, the variability of study designs, and selection bias, the prevalence of congenital uterine defects in women with reproductive failure is unknown. As a result, the present data on the frequency and likely causes of infertility in women with congenital uterine abnormalities is insufficient to draw any firm conclusions 8. In comparison to the general population, women with a history of loss or miscarriage and infertility tend to have a higher prevalence of congenital uterine defects. The unicornuate uterus is a rare anomaly that can lead to poor reproductive outcomes depending on a variety of factors, including variations in vascular contribution from the contralateral uterine and uteroovarian arteries, the extent of the unicornuate uterus’ muscular mass reduction, cervical competence, and the presence and extent of coexisting pelvic disease such as endometriosis.Laparotomy or laparoscopy can be used to remove the rudimentary horn. The bicornuate uterus is a frequent congenital defect that is linked to a successful pregnancy. The septate uterus is the most frequent structural uterine defect, and it’s linked to the highest rate of infertility. Without sight of the uterine fundus, hysterosalpingography (HSG) may display two hemicavities that are indistinguishable from a bicornuate uterus. TVUS is more accurate in this situation (100 percent sensitivity and 80 percent specificity).

Endometrial Polyps

Endometrial polyps are benign, localised endometrial overgrowths. They’re frequently found during the course of a study into irregular uterine bleeding and infertility. The link between endometrial polyps and fertility is poorly understood. Hysteroscopy is the gold standard for diagnosis, and hysteroscopic polypectomy is still the treatment of choice. Polyps can deform the uterine cavity, reduce endometrial receptivity, and increase the likelihood of implantation failure. A recent Cochrane review attempted to determine the impact of hysteroscopic polypectomy on intrauterine insemination outcomes (IUI). In comparison to diagnostic hysteroscopy and polyp biopsy alone (OR 4.4, 95 percent CI 2.5 to 8.0, and P 0.00001), hysteroscopic removal of polyps prior to IUI appears to improve the odds of clinical pregnancy (OR 4.4, 95 percent CI 2.5 to 8.0, and P 0.00001). In a group of women who had repeated implantation failure after IVF, hysteroscopic polypectomy resulted in a statistically significant improvement in implantation and clinical pregnancy rates. Finally, polypectomy before to IUI or IVF (even in cases of previous implantation failure) appears to boost the chances of conception 9.

Assisted Reproductive Technology (ART)

There have been studies published that look at the influence of office hysteroscopy (OH) on the pregnancy rate in IVF patients. Following a recurrent IVF failure, hysteroscopy has been shown to improve the chances of conception in the succeeding IVF cycle, both in those with abnormal and normal hysteroscopic findings. In 217 infertile women, the safety and diagnostic utility of hysteroscopy before IVF were investigated. Hysteroscopy revealed intrauterine lesions (polyps, septa, submucosal leiomyomas, or synechiae) in 69 women (31.8%), prompting surgical hysteroscopy. In the diagnosis of intrauterine abnormalities, diagnostic hysteroscopy has much higher sensitivity than TVS and HSG, according to the authors. As a result, diagnostic hysteroscopy should be performed before IVF in all patients, including those with normal TVS and/or HSG findings, because a considerable percentage of them have undiscovered uterine illness that could compromise reproductive treatment success10.


  1. Islam Sidky, Role of Hysteroscopy in Infertility Assessment, Int J Gynecol Clin Pract 5: 140, 2018.
  2. Taylor and V. Gomel, “The uterus and fertility,” Fertility and Sterility, vol. 89, no. 1, pp. 1–16, 2008
  3. Kilic Y et al., Validity and efficacy of office hysteroscopy before in vitro fertilization treatment. Arch Gynecol Obstet 287: 577-581, 2013.
  4. Bosteels, et al., “Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities,” Cochrane Database of Systematic Reviews, no. 1, Article IDCD009461, 2013
  5. Bosteels J et al., Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2013;1:CD009461.
  6. Bosteels J et al., The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematicreview. Hum Reprod Update 2010; 16:1 –11.
  7. The Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons, “Myomas and reproductive function,” Fertility andSterility, vol. 90, no. 5, pp. S125–S130, 2008.
  8. -A. M. Hassan, S. A. Lavery, and G. H. Trew, “Congenital uterine anomalies and their impact on fertility,” Women’s Health,vol. 6, no. 3, pp. 443–461, 2010.
  9. Stamatellos et al., “Pregnancy rates after hysteroscopic polypectomy depending on the size or number of the polyps,” Archives of Gynecology andObstetrics, vol. 277, no. 5, pp. 395–399, 2008.
  10. Lorusso, O. Ceci, S. Bettocchi et al., “Office hysteroscopy in an in vitro fertilization program,” Gynecological Endocrinology,vol. 24, no. 8, pp. 465–469, 2008.

Pic Credit by Hysteroscopy – First fertility phnom penh center

Dr Sarbani Mandal Dr Sarbani Mandal MBBS (Hons.), MS (G&O), MRCOG 1, Senior Resident, Bhagajatin State General Hospital, Kolkata
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