The role of diagnostic and interventional hysteroscopy in the management of fertility disorders

¹Department of Gynecology and Obstetrics, University Hospital of Monastir, Monastir, Tunisia, ²Maternal Center of Tunis, Tunis, Tunisia

^&Corresponding author
Fathi Mraihi, Maternal Center of Tunis, Tunis, Tunisia

Introduction    

According to the WHO, "Infertility is a medical condition of the reproductive organs defined by the inability of a couple to achieve a clinical pregnancy after one year of regular unprotected sexual activity." The study of the infertile couple is a complex process with several components: anatomical, functional, and psychological. This process must begin in parallel with both partners, at least after one year of unprotected intercourse [1]. Hysteroscopy (HSC), a visual examination of the uterine cavity, is indicated for fibroids, polyps, intrauterine synechiae, and congenital abnormalities. It is also used to confirm an abnormality that has already been detected by ultrasound. Hysteroscopy may be used for diagnostic or therapeutic purposes. For most intrauterine abnormalities, it has emerged as the most effective method for both diagnosis and therapy [2]. This study aims to analyse the effectiveness of hysteroscopy in the assessment of infertility.

Methods     

Study design: this was a retrospective descriptive study of the records of women presenting with primary or secondary infertility who underwent hysteroscopy with or without operative hysteroscopy over 9 years from January 2009 to December 2017. This study was conducted at the Obstetrics and Gynecology Department of the Fatouma Bourguiba Hospital in Monastir.

Study population and inclusion criteria: this is an exhaustive sample of cases of women with infertility for more than one year who were treated in our department and required hysteroscopy. We included in our study all women who met the inclusion criteria and whose files were usable. Patients who were lost to follow-up were excluded from the study.

Data collection and study variables: data were collected from hospital records, outpatient consultation records, and surgical reports. The variables studied were epidemiological (age, geographical origin, address, level of education), clinical (habits, medical and surgical history, gynecological and obstetrical history, clinical examination data), biological (results of biological examinations, ultrasound, diagnostic and operative hysteroscopy data, and fertility after these procedures). To reduce the risk of bias associated with data collection, this task was performed by a previously trained physician.

Statistical analyses: all analyses were carried out using Microsoft Excel 2016. Quantitative variables were presented as mean ± standard deviation (min-max), and qualitative variables were presented as numbers and percentages.

Ethical considerations: the study was conducted with the approval of the department heads. Data collection was anonymous, in accordance with ethical considerations.

Results     

Between January 2009 and December 2017, 86 diagnostic hysteroscopies were performed in 86 patients with infertility, of whom 61 (70.93%) underwent operative hysteroscopy. The age of our patients ranged from 24 to 44 years, with a mean of 34 years. Abdominal surgery was performed in 15 patients (17.41%). The mean age at menarche in our study was 13 years. In the 56 patients followed for secondary infertility, the mean number of pregnancies was 2.1 (1-8). Of these patients, 21 were primigeste. Regarding parity, nulliparity was observed in 58.13% of cases. 41.87% of the patients in our series had at least one child with a variation of parity between 1 and 3 children. The mean parity was 0.94 (0-3). Fifty-two patients had a history of spontaneous abortion (59.30%). Thirty-seven of these patients had undergone post-abortion curettage (43.02%). None of our patients were using oral contraceptives or intrauterine devices. Fifteen patients reported an irregular cycle (17.44%). Primary infertility was found in 30 patients (34.88%) with a mean infertility period of 4.36 years (1-17 years). Secondary infertility was found in 56 patients (65.12%), with a mean infertility period of 5.59 years (2-15 years). In our series, 3 patients had ectopic pregnancies treated medically, and 10 had ectopic pregnancies treated surgically. Three patients underwent tubal surgery for distal tubal obstruction. One patient had undergone surgery for ovarian cyst, 3 had undergone tubal plasty, 2 had undergone surgery for a breast node. Three had undergone surgery for uterine fibroid, 4 had undergone in vitro fecundation without success. Most patients underwent pelvic and endovaginal ultrasound with hysterosalpingography, hysterosonography, cervico-vaginal smear, MRI, and hormonal evaluation (follicle stimulating hormone, luteinizing hormone, prolactinemia) and a spermogram of the husband.

All diagnostic hysteroscopies were carried out between days 6 and 10 of the first period of the cycle. All patients underwent initial cervical preparation with misoprostol and cervical dilation with Hagar's candles. The fluid used for dilation was saline in all cases. Of the planned diagnostic hysteroscopies, 3 were missed, 9 were normal and 33 were abnormal. Eleven (11) patients had fibroids. Hysteroscopy revealed an endometrial polyp in 12 cases. The uterus was septated in 4 cases and bicornuate in one case. Eleven patients had fibroids. Hysteroscopy revealed an endometrial polyp in 12 cases. The uterus was septated in 4 cases and bicornuate in 1 case. Table 1 shows the different abnormalities found on hysteroscopy according to the type of infertility. A comparison was made between the abnormalities found on hysterography and those found on diagnostic hysteroscopy. Table 2 shows the percentage of agreement for the different abnormalities. Diagnostic hysteroscopy was followed by operative hysteroscopy in 61 cases (70.93%). Uterine synechiae were removed through the hysteroscope tip in cases of simple synechiae (18 cases, 20.93%). Complex uterine synechiae were removed by loop electrosurgery in 21 patients (24.41%). Diathermic loop polypectomy was performed in 16 patients. Uterine fibroids were removed by loop diathermy in 12 cases. The uterine septum was removed in 4 cases (4.65%). The procedure was complicated in 9 cases. The procedure could not be performed in 3 patients. It was complicated by uterine perforation in 3 cases and moderate bleeding in 3 others. Follow-up of patients who underwent diagnostic and operative hysteroscopy revealed 27 cases of pregnancy: 11 pregnancies were achieved after cure of synechiae, 5 pregnancies after polypectomy, 2 pregnancies after myomectomy and 9 pregnancies after diagnostic hysteroscopy. The pregnancy rate was 31.40%.

Discussion     

Hysteroscopy is an ideal method of examining the uterus in women with primary or secondary infertility. It allows visualization of the uterine cavity and the cervico-isthmic progression under direct vision. Innovations in endoscopic procedures in recent decades have made hysteroscopy more accessible to gynecological surgeons. Uterine abnormalities are a factor not only in infertility but also in recurrent miscarriage. Two to 3% of infertility is due to strictly uterine causes. However, intrauterine abnormalities are considerably more frequent (40-50%) in women who are unable to get pregnant [2]. The frequency of uterine abnormalities found during diagnostic hysteroscopy for infertility varies from 75% to 89.55%. Diagnostic hysteroscopy remains the gold standard for uterine exploration [3]. Indications range from metrorrhagia to infertility. Normal diagnostic hysteroscopy shows an endo-cervical canal with fine and pinkish mucosa. The uterine cavity is triangular with a superior base; the left ostium is higher due to the dextrorotation of the uterus [4]. In our series, the frequency of normal hysteroscopy in infertility exploration varies between 9.55% and 25%. The rate of abnormal hysteroscopy increases with the age of the woman, 30% at 30 years and 60% at 42 years [4]. Hysteroscopy has become the diagnostic and interventional tool of choice for most intrauterine conditions [4]. Diagnostic hysteroscopy has a high reliability and sensitivity in the evaluation of intrauterine lesions (polyps, submucosal fibroids, synechiae) [5]. This method has the advantage of being minimally invasive, easy to perform, more diagnostic than ultrasound, and has now replaced hysterosalpingography in most intracavitary diseases. Ultrasound is still the first-line test for abnormal bleeding and, in the case of infertility, remains an indispensable tool for etiological research, in addition to other diagnostic tools [5].

Agostini et al. report that despite the development of ultrasound and hysterosonography as part of infertility assessment, hysteroscopy remains the most effective examination for evaluating the uterine cavity [6]. Hysteroscopy has a higher sensitivity and specificity than ultrasound in the identification of uterine anomalies [7]. Hysterosalpingography is a crucial test in the context of infertility because it provides a great evaluation of tubal permeability while visualizing the genital tract from the cervix to the tubal region. However, pelvic endoscopy is the reference method [8]. Hysterosalpingography and hysteroscopy remain two complementary methods of exploring the uterine cavity in the evaluation of infertility, with hysterosalpingography being one of the first examinations to be performed as a primary indication in the evaluation of tubal permeability [9]. Hysteroscopy is useful in exploring the uterine cavity in all IVF candidates [10]. It promotes endometrial "inflammation", which could promote a cascade of biological responses with the secretion of cytokines, growth factors, interleukins, and other so-called pro-implantation proteins [11]. Surgical hysteroscopy is a real surgical procedure that takes place inside the uterus.

An instrument called a resector is inserted into the uterus using various instruments to perform surgical procedures. In our study, 61 surgical procedures were performed under operative hysteroscopy, divided into 39 treatments of synechiae, 20 polypectomies, 12 myomectomies, and 4 septoplasties. Hysteroscopy carries some risks, but they are generally rare; accidents and incidents have been reported in the literature, with different estimates of their frequency, ranging from 1.5 % to 11%, with an average of 2% [9]. Perforation is the most common adverse event reported in the literature, followed by bleeding, infection, and metabolic complications [12]. Uterine perforation is the most commonly reported complication. The rate of uterine perforation varies from 0.76% to 2% depending on the series [13]. Bleeding is observed in 0.16% to 23.6% of cases. Infectious complications are described as uncommon, rare and favorably treated with antibiotics. The incidence reported in the literature varies from 0 to 3% [14]. Metabolic disorders and air embolism have been described, but are very rare.

Limitations: the limitations of our study include its retrospective nature, with all the difficulties associated with data collection, and its single-center design, which may explain the relatively small size of the study group

Conclusion     

Hysteroscopy has always been considered a necessity by gynecologists. The majority of intrauterine abnormalities causing fertility problems can now be diagnosed and treated by hysteroscopy, which has replaced the highest level of care in this field. This method has demonstrated a higher diagnostic accuracy than other investigative tools and has facilitated the intracervical lesion approach with all the advantages it offers as a minimally invasive technique for both patient and physician. Consequently, diagnostic and surgical hysteroscopy is an effective tool in the evaluation and management of the uterine cavity and is used systematically in cases of uterine cavity abnormalities detected by hysterosalpingography, pelvic and endovaginal ultrasound, unexplained infertility, and medically assisted reproduction.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Asma Korbi, Farouk Ennaceur: drafting the article. Farouk Ennaceur: acquisition of data. Fathi Mraihi, Asma Korbi: revising the article. All the authors have read and agreed to the final manuscript.

Tables     

Table 1: analysis of anomalies detected by hysteroscopy, according to type of infertility

Table 2: percentage of agreement hysterosalpingography (HSG) vs hysteroscopy (HSC)

References