Hysteroscopy, as the name suggests (hystero
= uterus; scopy = to see), is a surgical procedure in
which a telescope is inserted inside the uterus to examine
the uterine lining. This procedure can assist in the
diagnosis of various uterine conditions which can cause
infertility, such as:
submucous (internal) fibroids
scarring (adhesions or synechiae)
endometrial polyps
uterine septa and other congenital
malformations
Before performing hysteroscopy, a hysterosalpingogram
(an x-ray of the uterus and fallopian tubes) may be
performed to provide additional information about the
cavity which can be useful during surgery. Many doctors
will also do a vaginal ultrasound as a diagnostic aid.
Diagnostic hysteroscopy is usually conducted on a day-care
basis with either general or local anesthesia and takes
about thirty minutes to perform.
The first step of hysteroscopy involves
cervical dilatation - stretching and opening the canal
of the cervix with a series of dilators. Once the dilatation
of the cervix is complete, the hysteroscope, a narrow
lighted telescope, is passed through the cervix and
into the lower end of the uterus. A clear solution (Hyskon
or glycine) or carbon dioxide gas is then injected into
the uterus through the instrument. This solution or
gas expands the uterine cavity, clears blood and mucus
away, and enables the surgeon to directly view the internal
structure of the uterus.
The doctor systematically examines the
lining of the cervical canal; the lining of the uterine
cavity; and looks for the internal openings of the fallopian
tubes where they enter the uterine cavity - the tubal
ostia.
Some doctors may do a curettage (a surgical
scraping of the inside of the uterine cavity) after
the hysteroscopy and send the endometrial tissue for
pathologic examination.
The technique of hysteroscopy has also
been expanded to include operative hysteroscopy. Operative
hysteroscopy can treat many of the abnormalities found
during diagnostic hysteroscopy at the time of diagnosis.
The procedure is very similar to diagnostic
hysteroscopy except that operating instruments such
as scissors, biopsy forceps, electocautery instruments,
and graspers can be placed into the uterine cavity through
a channel in the operative hysteroscope. Fibroid tumors,
scar tissue (synechiae or adhesions), and polyps can
be removed from inside the uterus. Congenital abnormalities,
such as a uterine septum, may also be corrected through
the hysteroscope.
In this video, you can watch Dr Anjali Malpani
perform an operative hysteroscopy, in which she performs
an adhesiolysis to remove intrauterine adhesions to
treat Ashermann's syndrome
This is what the surgeon does and sees on the video
screen when actually performing an operative
hysteroscopic adhesioloysis.
A relatively new method for treating
proximal tubal obstruction (cornual blocks, where the
tubes are blocked at the utero-tubal junction) is that
of hysteroscopic tubal cannulation. Many studies have
shown that this kind of block is often because of mucus
plugs or debris which plug the tubal lining at the uterotubal
junction which is as thin as a hair. It is now possible
to pass a fine guidewire through the hysteroscope into
the tubes, and thus remove the plug or debris and open
the tubes - thus restoring normal tubal patency with
"minimally invasive surgery"!
Another advance has been the development
of the method of falloposcopy - in which a very fine
flexible telescope is passed into the tube through the
hysteroscope, so as to visualize the interior of the
entire tube.
After a hysteroscopy, patients often
have cramping similar to that experienced during a menstrual
period; and some vaginal staining for several days.
Regular activities can be resumed within one or two
days after surgery. Sexual intercourse should be avoided
for a few days or for as long as bleeding occurs.
Complications occur rarely during
hysteroscopy. In a few cases, infection of the uterus
or fallopian tubes can result. Occasionally, a hole
may be made through the back of the uterus - a perforation.
However, this is usually not a serious problem because
the perforation closes on its own. Frequently, when
extensive operative hysteroscopy is planned, diagnostic
laparoscopy is performed at the same time to allow the
surgeon to see the outside as well as the inside of
the uterus to try to reduce the risk of accidental uterine
perforation. Other possible complications include allergic
reactions and bleeding.
Polyps
Endometrial or uterine polyps are soft, fingerlike growths
which develop in the lining of the uterus (the endometrium).
They develop because of excessive multiplication of
the endometrial cells, and are hormonally dependent
, so that they increase in size depending upon the estrogen
level. They can usually be detected on an ultrasound
scan if this is done mid-cycle, when estrogen levels
are maximal, but are easily missed if the scan is not
done at the right time of the menstrual cycle. Polyps
are an uncommon but important cause of infertility,
because they can easily be removed during hysteroscopic
surgery.
Fig 1. Uterine polyp as seen during hysteroscopy
Fig 2. Uterine polyp seen during ultrasound scan after
infusion of saline which outlines the polyp in the cavity
Fibroids
While the commonest problem found in the uterus is a
fibroid (myoma or leiomyoma), this is rarely a cause
of infertility, and is usually an incidental finding
of little importance. Fibroids are common benign smooth
muscle tumors which arise in the wall of the uterus,
and may be single or multiple. About 25% of all women
over the age of 35 have fibroids.
Most fibroids develop in the wall of
the uterus (intramural ) or protrude outside of the
uterine wall (subserous fibroids), and these can usually
be left alone, since they do not hinder fertility, and
neither do they cause problems during the pregnancy.
In fact, unnecessary surgery to remove the fibroid often
causes more harm than good. This surgery often creates
adhesions, which causes the tubes to get blocked.
However, if the fibroids are very large,
they may need surgical removal, and this procedure is
called a myomectomy. Some doctors give an injection
of a GnRH analog prior to surgery in order to shrink
the fibroid and make surgery technically easier. When
performed by an expert, it is a safe and effective procedure
which can be accomplished with minimal blood loss. However,
sometimes because of uncontrollable bleeding the surgeon
may be forced to remove the entire uterus (a procedure
called a hysterectomy), and this is obviously a disaster
for the infertile woman!
The standard technique for removing
a fibroid is through open surgery (laparotomy). It is
now also possible to remove fibroids through the laparoscope,
but laparoscopic myomectomy does not allow for optimal
reconstruction of the uterus. Submucous fibroids are
an important cause of infertility, because they interfere
with implantation of the embryo, by acting as a foreign
body. These are best removed by an operative hysteroscopy.
While surgery can remove the fibroid, it can recur again,
and most doctors advise the patient to try to conceive
as soon as possible after surgery.
Fig 2. Schematic showing a submucous fibroid; and a
subserous fibroid compressing the right fallopian tube
Fibroids may grow larger during the
pregnancy, but usually pregnancy and delivery are uneventful.
In rare cases, after a myomectomy, uterine rupture may
occur during pregnancy or delivery, and this complication
may result in severe blood loss, fetal loss and even
maternal death.
Because of the potential for catastrophic
results, it is recommended that women have cesarean
deliveries in the following circumstances: 1) when the
myomectomy involved full-thickness incision of the uterine
wall or multiple deep uterine incisions or 2) when myomectomy
was complicated by infection which may have weakened
the uterine wall or 3) when there is doubt regarding
the adequacy or extent of the uterine repair.
The uterus was often a neglected organ
in the infertility workup, partly because we did not
have the tools to study it properly. Hysteroscopy, hysterosalpingography
and vaginal ultrasound are all complementary procedures
for evaluating the uterine cavity in the infertile woman.
The HSG is good for looking for polyps, adhesions and
septa which appear as "filling defects" on the X-ray.
However, careful radiologic technique is a must. Vaginal
ultrasound is excellent for detecting submucosal fibroids
or polyps, which can be missed on hysteroscopy and HSG.
Of course, the major advantage of hysteroscopy is it
offers the chance of treating the problem as well!
We are now also developing newer techniques
to study the uterus. One of our major areas of ignorance
today is the complex process of embryo implantation.
It is obvious that the endometrium has a key role to
play in this process, in which the embryo has to appose
and attach itself to the maternal endometrium and invade
into it. At present, the tools we have to study endometrial
function and receptivity are very crude. They include
primarily transvaginal ultrasound, to assess the endometrial
thickness and texture, but this provides very limited
and indirect evidence of endometrial functions. Colour
Doppler ultrasound has also been used to assess endometrial
blood flow ( perfusion), but its utility is limited.
Since embryo-endometrium interaction
is a biochemical process, a lot of study has been done
on the role of the molecules involved in this process.
Recent research has shown that the normal endometrium
contains various cell adhesion proteins called integrins,
which allow the embryo to interact with it. Studies
have shown that the endometrium of some infertile women
is deficient in some of these integrins, and this deficiency
may be responsible for failure of the embryo to implant
successfully. Thus, testing the endometrium for beta
integrin can be a useful marker for uterine receptivity.
This test involves doing an endometrial biopsy at a
specific point in the menstrual cycle, and evaluating
this with special staining techniques, but is only available
on a research basis so far.
