The role of endoscopy in ART Femi Olarogun HART Clinic, Groote Schuur Hospital and UCT Private Hospital Cape Town

Artificial Reproductive Techniques In- Vitro Fertilization (IVF) with or without Intracytoplasmic sperm injection (ICSI) GIFT- Gamete intrafallopian transfer Zygote intrafallopian transfer ZIFT or tubal embryo transfer (TET) ART now accounts for 1-3 % of live births in the US and Europe

Endoscopy A procedure in which an instrument is introduced into the body to give a view of its internal parts. Usually through a natural orifice In Gynaecology this would refer to hysteroscopy and in a much broader sense laparoscopy We would mostly confine ourselves to the role of hysteroscopy with a brief mention about the role of laparoscopy

Introduction Hysteroscopy is a valuable tool for diagnosis and treatment before and after ART Indications include submucosal fibroids, endometrial polyps, uterine septum, intrauterine adhesions, chronic endometritis and retained POCs/foreign bodies Other uses would be in proximal tubal occlusion, failed IVF and T1 miscarriages

Intracavitary fibroids

Type 0 sub-mucosal fibroid

Submucosal Fibroids and IVF Intra-cavitary fibroids significantly affect the chances of IVF Hysteroscopic resection is the method of choice to treat these and pregnancy rates improve following treatment A two stage procedure may be necessary in patients with type 2 fibroids

UTERINE POLYPS Very common intra-uterine pathology Incidence is 6-8% in women undergoing IVF and removing them appears beneficial Hysteroscopic polypectomy is the treatment of choice- scissors, grasping forceps, morcellator or bipolar electrosurgical probe can be used. Acceptable to look grasp blindly and do a “relook” to confirm removal

Multiple polyps

Polypectomy

Asherman syndrome/intrauterine adhesions

ASHERMAN SYNDROME Asherman syndrome/uterine synechiae was described in 1948 Could be responsible for infertility and failed implantation following embryo transfer Hysteroscopic resection is the gold standard for treatment

Asherman -Treatment In severe cases, ultrasound guidance and/or laparoscopy may help decrease complications Use of sharp scissors may be beneficial as it avoids thermal injury caused by electrosurgery though this may be necessary Aim is to excise the bands. Intrauterine catheter (10 days) is effective and repeat hysteroscopies are often necessary. Post operative estrogen therapy is advised IUD (3 months) appears to be more effective than intrauterine gel or no intervention

Post scissors resection

Uterine septum Uterine septum is the commonest type of uterine defect Affects implantation by alterations in the endometrium Hysteroscopic resection is the method of choice Laparoscopic assistance and or endometrial thinning may be employed Improvement in implantation rates can be expected after resection

Retained products Patients with previous evacuations may have retained products or in some cases iatrogenic foreign bodies This induces a chronic inflammatory state not conducive for implantation Hysteroscopy has been compared to blind D and C in these cases and has been found to be superior Spontaneous conception rates and implantation rates following IVF are expected to improve

Chronic endometritis Asymptomatic inflammation of the endometrium Some studies have demonstrated association with recurrent miscarriage, infertility and implantation failure Hysteroscopy often shows “micropolyps” oedema and diffuse hyperaemia. Diagnosis could be confirmed on culture. However no evidence that treatment improves outcome

Failed IVF Hysteroscopy is indicated in women who have had failed IVF especially in the presence of good embryos even when ultrasound is normal Hysteroscopy has been shown to be useful in diagnosing previously unknown uterine pathology May also facilitate future embryo transfer as well as trigger a favorable immunological response that may improve pregnancy rates

Hysteroscopic tubal occlusion Studies have consistently shown that the presence of a hydrosalpinx is associated with poor IVF outcome The live birth rate is half the rate in those without hydrosalpinges Laparoscopic salpingectomy is the method of choice but hysteroscopic essures have been used successfully Hysteroscopic occlusion often reserved for women who are poor candidates for laparoscopy

Uterine scratching Endometrial injury prior to embryo transfer seems to improve the chances of pregnancy Seems effective if done between day 7 of the previous cycle and day 7 of the ET cycle Seems to have a negative impact if done on the day of egg retrieval Evidence comes from studies of moderate quality Methods include at hysteroscopy or in the office using a pipelle or similar

Conclusion Hysteroscopy is an integral part of the work up and treatment of patients requiring ART Numerous intra-cavitary conditions may affect the ability of the fertilized embryo to implant Even in the presence of a normal ultrasound Hysteroscopy has been shown to detect significant intrauterine pathology The advantage of hysteroscopy is that most pathology is subject to ”see and treat” and since this is mostly an out-patient procedure, it makes a one stop system possible for the patient

Thank you