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

2. 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

3. 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

4. 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

5. Intracavitary fibroids

6. Type 0 sub-mucosal fibroid

7. 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

8. 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

9. Multiple polyps

10. Polypectomy

11. Asherman syndrome/intrauterine adhesions

12. 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

13. 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

14. Post scissors resection

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Thank you