Fertility Enhancing Hysteroscopic SurgeryDr Sujoy DasguptaMBBS (Gold Medalist, Hons) MS (Obst & Gynae- Gold Medalist) DNB FIAOG

Assistant Professor: SRIMSH, Durgapur

Consultant:

RSV Hospital, Kolkata

Techno India Hospital, Kolkata

Behala Balananda Brahmachary Hospital, Kolkata

Hindusthan Health Point Hospital, Kolkata

Secretary, Perinatology Committee: BOGS- 2016-17

Managing Committee Member: BOGS- 2016-17

15 Publications: National and International Journals

Infertility- a big enigma?

Endometrium- Friendly or Hostile?

• Uterine factors- Found in 2-3% of the couples struggling to conceive

• can be present in 10-15% cases of “unexplained subfertility”

Hysteroscopy

• Uterine Pathology in TVS

• Unexplained Subfertility

• Subfertility with Repeated Miscarriage

• IVF Failure

Operative Hysteroscopy Enhancing Fertility

• Polypectomy

• Myomectomy

• Adhesiolysis

• Septum Resection

• Tubal Canulation

Endometrial Polyp

Polyps and Infertility

• can distort the endometrial cavity

• may have a detrimental effect on endometrial receptivity

• Frequently associated with obesity, diabetes, PCOS (hyperestrogenism)

• Infertile women are more likely to be diagnosed with an endometrial polyp (Level B)*

*AAGL Practice Report

7

Management algorithm for polyps

Annan JJ, Aquilina J, Ball E. The management of endometrial polyps in the 21st century. The Obstetrician & Gynaecologist 2012;14:33–38.

Evidences

9

Bosteels J, et al. Cochrane Database Syst Rev. 2015 Feb 21;(2):CD009461.

IUI the hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy

P´erez-Medina T, et al. Hum Reprod 2005;20:1632–5

IUI Hysteroscopic polypectomy increases pregnancy rate

Stamatellos I, et al. Arch Gynecol Obstet. 2008 May;277(5):395-9.

IVF In women in whom the only reason for subfertility was endometrial polyps, hysteroscopic polypectomy improved the rate of spontaneous conception regardless of size or number of polyps

Ben-Nagi J, et al.. ReprodBiomed Online 2009;19:737–44

IVF Polypectomy improves implantation rate

10

AAGL Guideline

•Hysteroscopic Polypectomy is the Gold Standard Treatment

•For the infertile patient with a polyp, surgical removal is recommended to allow natural conception or ART a greater opportunity to be successful (Level A).

Making certain diagnosis

1. TVUS -investigation of choice where available (Level B).

2. The addition of color or power Doppler improves accuracy (Level B).

3. SIS and 3-D imaging improves the diagnostic capacity (Level B).

4. Blind D/C biopsy should not be used for diagnosis of endometrial polyps (Level B).

AAGL Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

Fibroids

Fibroids and Subfertility

• Position

• Uterine receptivity

• Pressure Effect

• Blocking tubal ostia

• Cytokine production

• Poor implantation

Evidences

Pritts, et al. 2009 Meta-analysis

Removal of submucous fibroids seems to confer benefit in terms of pregnancy rates.

T. Shokeir, et al. 2010

RCT Women, with no other factors associated with infertility, undergoing hysteroscopic myomectomy had a better possibility of becoming pregnant.Irrespective of fibroid size, number, and location in both groups.

ClassificationT0 whole in

endometrial cavity

T1 >50% in endometrial cavity

T2 >50% in myometrium

• Location of myomas

• Number of myomas

• Size of myomas

• Asymptomatic/symptomatic

• Associated adenomyosis/endometriosis

• Distortion of endometrium

• Previous failed IVF cycles

• Previous pregnancy losses

• Available expertise and resources

• Other factors affecting fertility

Before decision making

AAGL Practice guidelines for sub mucous myomas :Level A

• Removal improves fertility esp for type 0 and type 1 but remains low as compared to normal uteri

• HSG is less sensitive and specific

• TVUS is less sensitive and specific than SIS/ Hysteroscopy/ MRI.

• MRI is superior in classification and realtionship of myomas with serosa .

• Cervical preparation can reduce trauma .

• Pre op use of GnRHa corrects anaemia

Intrauterine Adhesion

Asherman’s Syndrome

• Hypeomenrrhoea/ Amenorrhoea

• Infertility

• Recurrent Implantation Failure

• Recurrent Pregnancy Loss

• Preterm Labour

• Fetal Growth Restriction

• Intra-uterine Fetal Demise

• Placenta Accreta

ASRM Scoring for Intrauterine Adhesion

Look at... Size/description Score

Extent of

cavity

involved

<1/3 1

1/3–2/3 2

>2/3 4

Type of

adhesions

Filmy 1

Filmy and dense 2

Dense 4

Menstrual

pattern

Normal 0

Hypomenorrhoea 2

Amenorrhoea 4

Prognostic classification

Stage I (mild) 1–4

Stage II (moderate) 5–8

Stage III (severe) 9–12

Prognosis

• Restoration of menstruation- 70-90%

• Pregnancy Rate- 60-90%

(20-40% for severe disease and with recurrence)

• Term Pregnancy- 40-80%

• Pregnancy Complications- High

• Recurrence Rate- 30%

Advanced reproductive Care Inc 2002

AAGL Guidelines for Intra-uterine Synichae

• Hysteroscopic guidance is the method of choice with any tool.

• Laparoscopy may be combined in cases of dense and lateral adhesions.

• Antibiotics not a routine practice.

• IUCD/ Foley’s catheter- not recommended.

• Estrogens can be used to prevent recurrence.

• Hyaluronic acid gel can reduce adhesions

• Reassessment of cavity after 2 to 3 cycles with HSG or office hysteroscopy

Müllerian Anomalies

Uterine Anomalies

• spontaneous miscarriage –Septate > Bicornuate

• recurrent pregnancy loss

• malpresentation

• Fetal growth restriction

• preterm labour

• dysmenorrhea

• Association with Subfertility

Cause-effect relationship- ?

Septum, Infertility and Miscarriage

Septum and RPL

• All women with RPL should be assessed for uterine anomaly

RCOG Green Top Guidelines No 17. April 2011. The Investigation and Treatment of Couples with Recurrent First trimester and Second-trimester Miscarriage

Cutter vs Keeper

Hysteroscopic Metroplasty For Septate Uterus –A Meta-analysis Of 16 Published Series

Before After

Pregnancy 1062 491

Miscarriage 933 (88%) 67 (14%)

Preterm Delivery 95 (9%) 29 (6%)

Term Delivery 34 (3%) 395 (80%)

Homer,Liand, Cooke. Fertil Steril 2000

More EvidencesMollo et al. Fertil Steril 2009

Prospective Controlled Trial

women with unexplained infertility

Hysteroscopic resection of the septum improves the pregnancy rate and live birth rate

Ozgur et al. Reprod Biomed Online 2004

Retrospective Study

Before IVF Incomplete septum removal improves pregnancy, live birth rate and lowers risk of miscarriage

Ensieh ShahrokhTehraninejad. Int J Fertil Steril. 2013

Retrospective Analysis

Subfertility, RPL Hysteroscopic metroplasty improves live birth rate in both groups

Dural O, et al. JSLS, 2013

Retrospective Analysis

Subfertility with past H/O miscarriage

Hysteroscopic metroplasty improves live birth rate, irrespective of the method used

Fedele L, et al. Hum Reprod, 1996

Observational Study

Hysteroscopic Metroplastywith residual septum <1 cm

Does not adversely affect reproductive outcome

Cochrane Review, 2017

• Most studies of metroplasty for a septate uterus combine women with recurrent miscarriage and infertility, and no study has been published that randomizes infertile women to treatment versus no treatment. For this reason controversy exists as to whether infertile women should undergo metroplasty

C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty versus expectant management for women with recurrent miscarriage and a septate uterus,” Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD008576

“Prophylactic” Metroplasty

• May not increase fecundability, but may improve live birth rate

• Can prevent miscarriage and obstetric complications in IVF-pregnancy

• To be considered before IVF, especially if no other infertility factors were present

Hysteroscopic septal resection

40

• Principle- to horizontally divide rather than excise the septum.

• Aim- fundal myometrium is no less than 1.5 cm in depth

• IUD insertion for 3 months with estrogenisation is only recommended for complete or wide septa

Proximal Tubal Block

Screening Tests

Sensitivity Specificity

HSG 53% 87%

HyCoSy 93% 89%

Papaioannou S, et al. Tubal evaluation in the investigation of subfertility: a structured comparison of tests. BJOG 2004;111:1313–21.Papaioannou S, et al. Tubal assessment tests: still have not found what we are looking for. Reprod Biomed Online 2007;15:376–82.

Proximal Tubal Blockage (PTB)• Accounts for approximately 15% of cases of tubal factor infertility

Salpingitis isthmica nodosa (SIN) 40%

EndometriosisCornual Polyp

}10%

Cornual Spasm 20%

Stromal OedemaTubal debrisIntraluminal adhesionsViscid Secretion

}30%

• Suresh YN, Narvekar NN. TOG 2014;16:37–45.

Treatment of PTBIVF vs Tubal Surgery

• Patient’s preferences

• Age

• Associated Fertility Problems

• Cost, Expertise, Resources

• Risk of OHSS

Most of the PTB

• Fluroscopic Selective Salpingography

• Hysteroscopic Tubal cannulation

SIN • tubal resection and anastomosis of the diseased inflammatory area- highest success compared to tubal catheterisation or expectant management irrespective of tubal patency

Suresh YN, Narvekar N. Role of surgery to optimise outcome of assisted conception treatments. The Obstetrician & Gynaecologist 2013;15 91–8.

Recommendations

• For women with proximal tubal obstruction, selective salpingography plus tubal catheterisation, or hysteroscopic tubal cannulation, may be treatment options because these treatments improve the chance of pregnancy.

NICE Clinical guideline Fertility problems: assessment and treatment

American Society for Reproductive Medicine (ASRM)

• Hysteroscopy is the definitive method for the diagnosis and treatment of intrauterine pathology.

• Costly and invasive method for uterine cavity evaluation, it should be reserved for further evaluation and treatment of abnormalities defined by less invasive methods such as HSG and sonohysterography

Fertility and Sterility, vol. 98, no. 2, pp. 302–307, 2012

48

Routine Hysteroscopy before IVF?INSIGHT Trial

• Routine hysteroscopy does not improve livebirth rates in infertile women with a normal transvaginal ultrasound of the uterine cavity scheduled for a first IVF treatment. Women with a normal transvaginal ultrasound should not be offered routine hysteroscopy.

• Smit JG, et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet. 2016 Jun 25;387(10038):2622-9.

Take Home Message• Routine hysteroscopy before 1st IVF- ?

• Intrauterine Pathology- should be addressed by hysteroscopic diagnosis and treatment

• Hysteroscopic surgery increases chance of pregnancy and live birth-spontaneously/ after IUI/ IVF

• Vaginoscopic/ “No Touch” approach has several advantages

• Safe, cost-effective than conventional surgery

Bertrand Russel

Thank You