How useful is hystroscopic evaluation in cases of Unexplained infertility or Recurrent implantation Failures in IVF procedures?? One of the cause of RPL or say causes of Rec Implantation failure is some anatomical abnormality of endometrium which however can’t be picked up by Sonography alone. Therefore hysteroscopy is a must procedure for all cases of Unexplained infertility and Recurrent implantation Failures in IVF procedures :-Arguments in favour are as follows .Despite numerous developments in the field of assisted reproduction, the implantation rate remains low. A) Chromosomal and genetic abnormalities of the male sperm or female B) ovarian paracrine defects, C) embryonic aneuploidies or D) zona hardening are embryonal reasons for the failure of
Implantation. Bu what is little discussed is “ Intrauterine and endometrial integrity related abnormalities” . These are 1) thin endometrium,(demonstrable) altered expression of adhesive molecules and immunological factors(these are not demonstrable) may decrease endometrial receptivity.
Among the various etiologies that were
described, endometrial regularity played an important
role in infertility and success of in vitro fertilization
(IVF) programs. Hysterosalpingography, transvaginal
sonography, and saline contrast hystero sonography
are useful tools for detecting endometrial irregularity, but have their limitations. But , hysteroscopy showed to be more accurate in the
evaluation of intracavity pathology in comparison with
any other study. Many
trials showed the usefulness of uterine reassessment by
Hysteroscopy in women with IVF failures,. It is true that
there are other probable contribution factors such
as thrombophilia, and immunological disorders.
How to find out cause of unexplained subfertility?? After
taking history, physical exam, routine hematological,
biochemical, hormonal tests, spermiogram, also
flow cytometry, autoantibodies profile like anti-
Cardiolipin (aCL), Lupus Anticoagulant (LA), anti-
Phosphatidylserine (aPS), anti-phosphatidylethanolamine
(aPE), antinuclear antibodies (ANA), anti DNA, and
thrombophilia profile like methylenetetrahydrofolate
reductase (MTHFR) gene-prothrombine gene, factor
V Leiden gene, serum homocystein , protein C, Protein
S, anti-thrombin III, and karyotype have accomplished
in all women. All infertile women underwent
transvaginal ultrasonography and later
operative hysteroscopy)
in early follicular phase of the cycle (7th and 11th day
of the cycle) under general anesthesia, using dextrose
5% as distention medium. after exclusion of other
probable causes of Unexplained subfertility . / ICSI /IVF-ET failures, the findings . Some studies have compared hysteroscopy with sonographic
findings, then evaluated and analyzed with special
concern to age and duration of infertility.
. Abnormal sonographic
findings were observed in (52.8%) in which
endometrial irregularity, hyperplasia, and polyps were
the most common. Abnormal hysteroscopic findings
were observed in (59.5%) in which intrauterine
adhesions, endometrial hyperplasia, and polyps, were
the most common . Abnormal findings in
patients with ≤30 years were not significantly more
compared with older patients
However, significantly more hysteroscopic
abnormalities were found in the infertile patients with
more than 8 years infertility,
Also, single polyp and endometrial hyperplasia were
not significantly more in patients with ≤30 years old,
and ≤8 years infertility in comparison with older
patients and longer duration of infertility using
According to our results, sonography
is more specific (100%) but not sensitive (88.6%)
compared to the hysteroscopy, with false negative rate
of 19.4%.
However, hysteroscopy showed to be more
sensitive and specific in the evaluation of intracavity
pathology in comparison with sonography in selected
patients. Structural abnormalities correlated with the
presence of pathological abnormalities were seen in
94.3% of cases. Also in 13.2% of cases,
nonspecific endometritis was reported.
It has been shown cervical
abnormalities (synechia, polyp, and false passage)
and intrauterine abnormalities (polyp, hyperplasia,
adhesions and submucous myoma) in half of the cases
after 2 implantation failures in IVF. Also, uterine
abnormalities have been shown in women (18%) with
the history of IVF-ET failures who had normal
Hysteroscopy in repeated IVF/ICSI failures ...
Findings on hysterescopy (%)
Submucosal myoma
Single large polyp
Polypoid endometrium
Endometrial hyperplasia
Uterine cavity hypoplasia
Adhesion
Endocervical polyp
Multiple lesions
Without any finding
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