In The Name of God Abortion &Hysteroscopy Shirin Ghazizadeh Tehran University of Medical Sciences Aban 1393 Shirin Ghazizadeh Tehran University of Medical Sciences Aban 1393

Role of Hysteroscopy in Abortion Recurrent pregnancy loss (RPL) Retained tissue Polyp/myoma Uterine synechia Septate uterus Recurrent pregnancy loss (RPL) Retained tissue Polyp/myoma Uterine synechia Septate uterus

Recurrent pregnancy loss (RPL) >3 (non)consecutive losses of clinically recognized pregnancies <20 th w <500gr –(ectopic, molar, and biochemical pregnancies are not included) –It may be primary or secondary ASRM  >2 failed pregnancies (ultrasound or histopathological) >3 (non)consecutive losses of clinically recognized pregnancies <20 th w <500gr –(ectopic, molar, and biochemical pregnancies are not included) –It may be primary or secondary ASRM  >2 failed pregnancies (ultrasound or histopathological)

Retained tissue Hysteroscopy removal is much less traumatic

Retained fetal bones Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion. An intrauterine device-like effect Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion. An intrauterine device-like effect

Sub mucousal myoma / polyp Abnormal uterine bleeding Recurrent pregnancy loss Infertility Abnormal uterine bleeding Recurrent pregnancy loss Infertility

Polyps Premenopausal –symptomatic polyps –asymptomatic polyps >1.5 Postmenopausal –all endometrial polyps (Grade 1B)Grade 1B Premenopausal –symptomatic polyps –asymptomatic polyps >1.5 Postmenopausal –all endometrial polyps (Grade 1B)Grade 1B

Hysterscopic Myomectomy European Society of Hysteroscopy (ESH) –Type 0 - completely within the cavity –Type I - extend < 50 % into the myometrium –Type II - extend >50 % within the myometrium European Society of Hysteroscopy (ESH) –Type 0 - completely within the cavity –Type I - extend < 50 % into the myometrium –Type II - extend >50 % within the myometrium

Distinguishing myoma versus myometrium

Intrauterine adhesions

Trauma –missed or incomplete abortion, postpartum hemorrhage, or retained placental remnants Genital tuberculosis Trauma –missed or incomplete abortion, postpartum hemorrhage, or retained placental remnants Genital tuberculosis

Intrauterine adhesions Foley cath. compared with IUD –↑ Normal menses (81 versus 63%) –↑ conception rates (34 versus 23 %) –↓ Need for reoperation 5 mg estrogen daily for 30 days Foley cath. compared with IUD –↑ Normal menses (81 versus 63%) –↑ conception rates (34 versus 23 %) –↓ Need for reoperation 5 mg estrogen daily for 30 days

Uterine septum

semirigid or rigid scissors (5-7 French) Bi/unipolar wire (KTP/532), (Nd:YAG), or argon lasers. semirigid or rigid scissors (5-7 French) Bi/unipolar wire (KTP/532), (Nd:YAG), or argon lasers.

hysteroscopic correction of arcuate uterus prior to IVF? Measurement by sonohysterography –Fm (fundal myometrial thickness) –Cm (cornual myometrial thickness) Incision of the incomplete septum. Fm >11 mm Fm-Cm >5 mm, Measurement by sonohysterography –Fm (fundal myometrial thickness) –Cm (cornual myometrial thickness) Incision of the incomplete septum. Fm >11 mm Fm-Cm >5 mm,

Arcuate uterus Metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion. Improvement of uterine artery Doppler velocimetry indices after metroplasty Metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion. Improvement of uterine artery Doppler velocimetry indices after metroplasty

Outpatient hysteroscopy and subsequent IVF cycle outcome Meta-analyses of five studies –Improving result in subsequent IVF cycle (relative risk = 1.75, 95% CI ). Mini-hysteroscopy with no intervention before IVF treatment Meta-analyses of five studies –Improving result in subsequent IVF cycle (relative risk = 1.75, 95% CI ). Mini-hysteroscopy with no intervention before IVF treatment

"Chromohysteroscopy" 5 ml of 1% methylene blue dye Group I: 19 patients focal dark staining 10 cases of endometritis Group II: 15 patients diffuse light blue staining normal histopathology 5 ml of 1% methylene blue dye Group I: 19 patients focal dark staining 10 cases of endometritis Group II: 15 patients diffuse light blue staining normal histopathology

Conclusion(1) Diagnostic hysteroscopy should be a routine procedure during diagnostic laparoscopy in infertile women

Conclusion(2) Office mini-hysteroscopy should be incorporated in infertility work up