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- A Retrospective Observational Study

Priya Cheema¹ , Hrishikesh Pai² , Charumati Pekhale³

IVF Department,
Lilavati Hospital & Research Centre, Mumbai
What is the study about?
 To determine the diagnostic accuracy of
Hysteroscopy in detecting uterine
pathologies in pre ART candidates

 To study the incidence of intrauterine

pathologies in infertile patients undergoing
hysteroscopy prior to ART
What is the study about?
To evaluate the importance of subjecting the
patient to hysteroscopy prior to ART

Research Question
Should routine Hysteroscopy be a part of
routine workup in patients of infertility prior
to undergoing ART ?
 Infertility is “a disease of the reproductive
system defined by the failure to achieve a
clinical pregnancy after 12 months or more
of regular unprotected sexual intercourse”
according to WHO revised glossary of
assisted reproductive technology (ART)

 Affects 10-15 % of couples

 Despite advances in the field
of ART, only 1/3 rd of cycles
started end in a pregnancy
and 1/4th result in a live birth

 Intrauterine pathologies are found to be present in

25 - 50 % of infertile patients, more so in patients
of repeated implantation failures

 Exclusion of any intrauterine pathology is an

important step before subjecting the patient to

 Traditionally, the assessment of the

uterine cavity for the basic infertility
work-up has been performed by TVS
and hysteroscopy

 The place of routine hysteroscopy in

the management of infertile women
without other diagnosed or doubtful
intrauterine pathologies is still a matter
of debate
ESHRE (European Society of Human
Reproduction and Embryology)

 Indicate hysteroscopy to be unnecessary, unless it is for

the confirmation and treatment of doubtful
intrauterine pathology

NICE (National Institute for Health and Care

Excellence) guidelines (2004)

 Suggest that women should not be offered

hysteroscopy on its own as part of the initial
investigation unless clinically indicated because the
effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established
Review of literature

1. Role of Jain N1*, Gynaecolo Open OCT Hysteroscopy

Hysterosco Manchanda gy Access 2016 should be
py in R2, lekhi A1 endoscopy Journal of considered as
Evaluation and Chithra unit, PSRI, Gynecolog routine
of Infertility: S1 DELHI y investigation in
A ISSN: evaluation of
Retrospecti 2474-9230 women with
ve Study of primary and
100 Cases secondary
2. Evaluation Aisha M Gynecolog Reproducti APR Hysteroscopy
of IU Elbareg*, y ve System 2015 has a high
Pathology: Mohamed O Departme & Sexual diagnostic
Efficacy of Elmahashi nt, Disorders accuracy, with
Diagnostic and Fathi M Misurata Elbareg et possibility of
Hysterosco Essadi Central al., Reprod simultaneous t/t
py in Hospital, Syst Sex gives it
Comparison Libya Disord an irreplaceable
to HPE 2015 value in workup
Review of literature

3. Hysterosco Ashraf Dpt of Int J APR The IU lesions diagnosed

pic Findings Moini, Obstetrics Fertil 2012 by HSC in such pts
in Patients M.D.1, & Steril.201 ranges from 0.8%-
with A H/o Kiandok Gynaecolo 2 19.7%.Correction of
2 ht Kiani, gy,Tehran abnormalities
Implantatio M.Sc.1, university showed good outcome,
n Failures Firouzeh of Medical similar to that achieved
Following Ghaffari, Sciences. in patients with a N.HSC
IVF M.D.1 Iran
4. Hysterosco Padma Departme Internati NOV TVS,HSG & HSCare
pic Shukla*, nt of onal 2016 complementary
evaluation Kalpana Obstetrics Journal of in the evaluation of the
of uterine Yadav, and Reprodu infertile patient but HSC
cavity in Sakshi Gynaecolo ction, can diagnose small
cases of Mishra gy, S.S. Contrace intrauterine lesions more
infertility & Medical ption, Precisely & treat them
its College, Obstetric too. Routine HSC be
correlation Rewa MP s and included in the evaluation
with TVS & Gynecolo of the infertile couple
HSG gy

 Study Area: Lilavati Hospital and Research Centre

 Study population: 210 infertile women who attended our

infertility outpatient clinic between JAN 2016 to AUG
2017 over a span of 20 months for pre-ART investigations

 Inclusion Criteria:
Age between 18 - 45 yrs
ART Candidates (IVF,ICSI-ET, Oocyte/Embryo donation)

 Exclusion criteria:
Patient with H/o Diagnostic Hysteroscopy with normal
findings within the previous 6 months
Statistical Measures of outcome
 Method of measure of outcome of interest
 Frequency Sensitivity
 Specificity
Uterine pathologies visible on HSC and/or
on TVS as well as histopathology reports of
the same
Method of data collection :

 All women who presented to the IVF centre and met the
inclusion and exclusion criteria were considered

 The TVS was performed as a routine investigation before


 All hysteroscopies and endometrial procedures were

performed during any of the previous menstrual cycle
before the intended ART procedure, preferably the
immediate previous cycle under GA
 A rigid hysteroscope of 4 mm diameter with 30º
oblique view was put into the uterine cavity under
visual control and normal saline was used as the
distension medium, keeping the uterine pressure
between 100 and 150 mm of mercury

 On entering the uterine cavity, a systematic

inspection was conducted including the uterine
cornua, tubal ostia, uterine fundus, lateral, anterior,
and posterior uterine walls
 The use of a video system helped
to explain findings to the patient
observing the video screen, and
to record the procedure for future

Intrauterine lesions, such as,

 synechiae, polyps, sub mucosal
 myomas, septae, etc were
 treated surgically

 All patients were subjected to endometrial

biopsy and samples sent for
histopathological examination
The findings at Hysteroscopy were documented on a
special data collection form that included the following

 [1] The appearance and shape of the endocervical

 [2] The appearance of the endometrium
 [3] Shape of the uterine cavity
 [4] Presence and location of bilateral uterine ostia
 [5] Presence and location of structural anomalies
Age Group (years) No. of women Percentage
42 20 %
< 30
151 72 %
17 8%
> 40
Duration of infertility
160 76
47 22.40
3 1.60
No of previous IVF No. of women Percentage
attempts studied
None 59 28 %
One 126 60 %
Two 13 6.4 %
>Two 12 5.6 %

• The mean age at hysteroscopy was 31.8 years

(18 – 45 years)

• The duration of infertility ranged from 1 to 15 years

Comparative analysis between TVS, Hysteroscopy and
Histopathological findings
Pathologies TVS (n) HSC (n) HPE (n)
Normal 145 136 136
Endometrial Polyp 12 (24.4%) 21 (28.37 %) 20 (27%)
Endometrial 1 (2%) 2 (2.70 %) 3 (3.70%)
Endocervical Polyp 13 (26.53%) 12 (16.21%) 12 (16.21%)

Submucous Myoma 6 (12.24%) 10 (13.51%) 11 (15.21%)

Intrauterine 9 (18.36%) 17 (22.97%) 19 (25.67%)

Intrauterine Foreign 3 (6.12%) 2 (2.70%) -
Uterine cavity 3 (6.12%) 5 (6.75%) 5 (6.75%)
Cervical Stenosis 2 (4.08%) 3 (4.05 %) -

Blocked Ostia 0 1 (1.35%) -

Absent Ostia 0 0 -

Total pathologies 49 74 (35.23%) 70 (33.33%)

Statistical Analysis of Diagnostic Accuracy
Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Normal 100 100 100 89.16 100 93.79 100 100
Endometrial 100 71.4 99.48 100 95.24 95.0 100 95.96
Endometrial 98.40 66.6 100 100 97.4 100 100 99.52
Endocervical 100 100 100 99.47 100 92.31 100 100
Submucous 85.71 66.6 100 100 100 100 99.1 97.06
IU adhesions 90.48 65.5 100 100 100 100 98.96 95.02

IUForeignbody 100 100 100 99.52 100 66.67 100 100

Uterine cavity 100 71.4 100 100 100 100 100 99.03

Cervical 100 75 100 100 100 100 100 95.52

Blocked Ostia 100 50 100 100 100 100 100 99.52

Absent Ostia - - - - - - - -
Chart Title Chart Title
Normal findings
Pathologies detected Primary Secondary


65% 62%

40% of patients with abnormal findings had a H/o Implantation

 Commonest pathology – Endometrial polyp
27 % (20/74)
- Most common in
primary infertility
36.73 %

 2nd most common pathology - Intrauterine adhesions

25.67 % (19/74)
- Most common in
secondary infertility
48.71 %
 We noticed differences between TVS and
hysteroscopy in their diagnostic accuracy

 TVS in comparison to hysteroscopy had lower

sensitivity in the diagnosis of polyps
(71.14% versus 100%)

 In those cases in which hysteroscopy and histology did not

confirm the existence of an endometrial polyp, it was
actually a case of endometrial hyperplasia, but we had
diagnosed it as an endometrial polyp by TVS
 TVS in comparison to hysteroscopy

 Lower sensitivity in the diagnosis of Endometrial

(66.6% versus 98.4%)

 Lower sensitivity in diagnosis of

Intrauterine Adhesions
(65.5 % 90.48%)

 TVS could explain infertility in 23.2%

 Hysteroscopy could explain in 46 % cases

 The overall agreement between both methods was
moderate (Kappa= 0.414, P value - 0.0001)

 Significant correlation between

the two with Hysteroscopy
being a better diagnostic tool
(x2= 9.633, P value- 0.0019)

 The strength of agreement between Hysteroscopy

and TVS is considered to be ‘moderate’

 While that between Hysteroscopy and histology is


 Essential role of hysteroscopy in the diagnosis of intra uterine

pathologies is emphasized, especially in infertile patients

 However, hysteroscopy is not utilized as a routine investigation

for infertile women

 Some researchers believe that hysteroscopy is necessary for

treatment of suspicious uterine pathologies, whereas others
have found no benefit in fertility enhancement after treatment
of uterine anomalies
 The two main problems that argue against
the case of hysteroscopy are
 First, it is an invasive procedure
 Second, there is still an ongoing debate
about the real significance of the observed
intrauterine pathology on fertility
 Several studies have also been performed to find
out if hysteroscopic treatment of intrauterine
pathologies increases the success of ART

 Kirsop et al., suggested that intrauterine

abnormalities may be a cause for failure of ART

 Faghali et al., have also recommended screening the

uterus by hysteroscopy before proceeding with IVF,
to minimize implantation failures

 The role of hysteroscopy in patients with

previously failed IVF cycles has also been studied

 A recent systematic review and meta analysis of

two randomized and three nonrandomized
control trials on 1691 patients concluded that
hysteroscopy before a subsequent IVF attempt
significantly increases the odds for conception in
 Uterine lesions, such as hyperplasia, polyps and
leiomyomata have been shown in 18-50% of
women with repeated IVF failure

 It seems that these pathologies have been

missed during first evaluation and recurrent
implantation failure has occurred as a result of
these undiagnosed pathologies*

*Moini A, Kiani K, Ghaffari F, et al. Hysteroscopic Findings in Patients with A History of Two
Implantation failures following in vitro fertilization. Int J Fertil Steril.2012; 6(1): 27-30
 Hysteroscopy appeared to be more reliable in
diagnosis than TVS and offers the possibility of
simultaneous diagnosis treatment of endouterine
pathologies in infertile women

 Abnormal hysteroscopic findings have been

reported in patients with normal hysterography
or transvaginal ultrasonography
 The results of this study with sensitivity of
100% and specificity of 100% in diagnosis of
endocervical polyp uterine septa, intrauterine
foreign body, cervical stenosis confirmed the
results of other studies according hysteroscopy
as the gold standard in the diagnosis of
endouterine pathologies

 Advantage of TVS – information on the status of

the ovaries and follicles along with uterine
 We believe that HSC and TVS are
complementary to each other in the
evaluation of the infertile patient, each
evaluates the uterine cavity differently, with
their advantages and limitations

 HSC can diagnose even small intrauterine

lesions much more precisely that might
affect fertility and treat them simultaneously
 Hysteroscopy is a valuable, simple, safe, feasible,
highly tolerable, sensitive, specific, low risk and
minimally invasive method which allows an
adequate exploration of the uterine cavity under
vision and it also provides information about the
cervical canal

 We consider routine hysteroscopy should be

included in the evaluation of the infertile couple
prior to undergoing ART, more so in patients
with previous H/o Implantation Failure
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