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Office Hysteroscopy

Hysteroscopy is a diagnostic procedure used to assess the uterine cavity. Defects that can be found in the uterine cavity include polyps, sub-mucosal myomas, or scar tissue. All of these can affect fertility. Hysteroscopy is referred to as the ‘Gold Standard’ test because it allows complete visualization of the uterine cavity. Other methods to assess the uterine cavity include the hysterosalpingogram (i.e. HSG) and the saline infusion sonogram (i.e. SIS or sonohysterogram). The HSG is a procedure done in the hospital radiology department while the patient is on a fluoroscopy table. A speculum in placed in the vagina, the cervix is washed with an antiseptic and a balloon tipped catheter is placed in the uterine cavity. Some HSG’s are done with a metal clamp. We then inject the dye and several pictures are taken. There is no anesthesia. The X-Ray will show dye passing into the fallopian tubes and confirm free spill of dye into the peritoneum or blocked tubes. Defects may be seen in the uterine cavity such as polyps or myomas. Defects in the cervical canal will not be seen because the catheter tip is usually above this level. About 15% of these procedures will give false-negative results (i.e. normal HSG but actually have defect). The Saline Infusion Sonogram allows us to assess the uterine cavity as well as the wall of the uterus at the same time. It does not allow observation of the fallopian tubes like the HSG. Saline may be seen to flow into the pelvis with the SIS, but one does not know which tube is open. Like the HSG, the SIS may show lesions in the uterus an. Of course, neither procedure allows for treatment at the same time as diagnosis like hysteroscopy. Because hysteroscopy allows direct visualization by the physician and treatment, it is clearly the ‘Gold Standard’ of uterine assessment.

Hysteroscopy may be safely and conveniently performed in the office setting. It may be performed with local anesthesia or even intravenous sedation. There are benefits to an office-based procedure compared to a hospital-based procedure. The scheduling is much easier, the stress is much less, and the cost much less. When done in the hospital setting, the facility fee may be as much as $4000 and the surgeon fee almost $1000. The office-based procedure (i.e., facility and doctor fee is $1000, anesthesia $550) far more affordable. Some patients will not need sedation for the procedure and thus save more money. This is very important when patients are self-pay or have high deductibles with insurance. We offer the office-based procedure because of the great benefits it offers.

Hysteroscopic images of the uterus cavity

Figure 1. Normal uterus.

 

Figure 2. Large uterine polyp.

 

Figure 3. Excision of polyp at base.

 

Figure 4. Small polyps lower uterus cavity.

 

Figure 5. Uterus septum excised. Note lack of bleeding from base of septum.

 

Figure 6. Thin adhesions found in patient with failed IVF easily removed. Patient conceived subsequent cycle.

 

Office hysteroscopy and infertility/IVF patients

There have been a number of studies published in the scientific literature that indicates that office-based hysteroscopy identifies uterine defects in a large number of infertility patients. In 2008, Lorusso et al (Gynecol Endocrinol. 2008 Aug;24(8):465-9), reported on 866 consecutive patients, 555 before their 1st IVF cycle and 311 after 2 or more IVF cycles. 40% of the patients were found to have uterine cavity defects. In 2005, Bozdag et al (Reprod Biomed Online. 2008 Sep;17(3):410-5) performed hysteroscopy in patients that had failed IVF. About 50% had defects. When these were corrected at the time of hysteroscopy the pregnancy rates were the same as those with normal uterine cavities. Makrakis et al (J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):181-7) did hysteroscopy of patients with 2 failed implantation cycles of IVF. 36% had abnormalities and 22% had unsuspected lesions. The pregnancy rates increased after treatment. Doldi et al(Gynecol Endocrinol. 2005 Oct;21(4):235-7) in 2005 found essentially the same thing and encouraged hysteroscopy before IVF. A systematic review and meta-analysis (Reprod Biomed Online. 2008 May;16(5):712-9) of well controlled publications showed benefit of the procedure.

In summary, office-based hysteroscopy has many benefits to diagnose and treat uterine defects which should improve embryo implantation and pregnancy rates.
 

 

 

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