Hysteroscopy Newsletter is an opened forum to all professionals who want to contribute with their knowledge and even share their doubts with a word-wide gynecological community

Cesarean Scar Defect and Hysteroscopy

Isthmocele 2

Sometimes the healing process of the cesarean section scar is incomplete, with a disruption of the myometrium. In the literature there are several names used for this “gap”, being the terms “niche” or isthmocele the most commonly used. The real incidence is unknown however it might range between 24% to 56%. There seems to be a relationship between multiple previous cesarean section and CSD.

Frequently it is asyntomatic, but sometimes is responsible for menorrhagia, abdominal pain, dyspareunia and dysmenorrhea. Infertility might also be present, as the accumulation of blood in the pouch can lead to minimal retrograde passage of blood, to the uterine cavity, especially in retroverted uteri, causing inflammation or an adverse environment for embryo implantation.

Histeroscopy allows for the direct visualization of the defect. When passing throw the cervix, or just after it, a pseudocavity can be seen in the anterior wall. The typical sign is a “double arch”. The dome is often covered with fibrous tissue or congestive endometrium. Depending on the cycle phase blood clots can sometimes be seen. The is usually not necessary, but can be useful to rule out other conditions or to plan the corrective surgery.


Adenomyosis and Hysteroscopy


Adenomyosis refers to the presence of ectopic glandular tissue, located deep in the myometrum.

A 2014 review by Vercillini concluded that adenomyosis was associated with a 68% reduction in the likelihood of pregnancy in women seeking conception after surgery for rectovaginal and colorectal endometriosis. The same author reviewed the outcome of adenomyosis associated with IVF/ICS to conclude that women with adenomyosis had a 28% reduction in the likelihood of clinical pregnancy at IVF/ICSI compared with women without adenomyosis and a higher rate of spontaneous abortion.

Hysteroscopy allows for the direct visualization of the uterine cavity, however its ability to diagnose adenomyosis is limited.

Hydrosalpinx and Hysteroscopy


Around 10-30% of couples presenting with infertility have hydrosalpinx. Alternative treatments include achieving tubal occlusion by devices inserted hysteroscopically. Both Essure ® and Adiana ® have been used in this context, however for infertility purposes most of the studies have been done with Essure ®- off label use. The Essure® device is a spring like device consisting of a stainless steel inner coil and a nickel titanium elastic outer coil and polyethilne fibers. The device is usually performed in an outpatient setting, with local or no anesthesia at all. Sterilization is not immediate and women
should use additional contraception for another 3 months. Rosenfield et al. in 2005 reported the first successful live birth following Essure ® placement, in an obese woman with extensive pelvic adhesions.

A systematic review on the efficacy and safety of Essure® in the management of hydrosalpinx before IVF was published in 2014. Overall 115 women in 11 studies received Essure ®, which was successfully placed 96.5% of women and tubal occlusion was achieved in 98.1%. The subsequent IVF resulted in 38.6% pregnancy rate and 27.9% live birth rate per embryo transfer.


Asherman 2.jpg

The first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, but it was only after 54 years that a full description of Asherman syndrome (AS) was carried out by Israeli gynecologist Joseph Asherman. Specifically, he identified this pathology in 29 women who showed amenorrhea with stenosis of internal cervical ostium. The true
incidence is unknown and is estimated to be around 0,3% in the general population and up to 21% after postpartum curettage.

Intrauterine adhesions are composed of fibrotic tissue, which may result in the adherence of opposing surfaces. The adhesions could be filmy or dense, simple or multiple and focal or total. It is possible that, after injury to the endometrium, fibrosis may follow with the potential for adhesion formation. The impact of AS or adhesions is important. There seems to be a high rate of infertility, poor implantation and miscarriage.

The goals of the hysteroscopic treatment are: 1) restoration of the triangular cavity, 2) visualization and confirmation of permeability of the ostiums, at least one of them, 3) avoid the destruction of normal endometrium, 4) minimal manipulation of normal endometrium and 5) avoid uterine perforation.


Full article: Hysteroscopy Newsletter

Hysteroscopy book

Hysteroscopic Endometrial Embryo Delivery (HEED)

Hysteroscopy embryo.JPGHysteroscopic endometrial embryo delivery (HEED) is a beneficial technique in increasing clinical pregnancy rates, especially in patients with repeated failed IVF-ET attempts. Due to the objective and replicable nature of the hysteroscopic procedure along with increased accuracy of placement of embryo(s), efforts in reducing multiple pregnancies should now be more focused on increasing our knowledge of selecting embryo(s) with high survival potential for embryo transfer. Ectopic pregnancies from IVF will be minimized by using lower transfer volumes of 5 μl and visually confirmed positional placement of embryos away from the uterinecornu. Ectopics are almost eliminated when using the SEED technique for blastocyst embryo transfer.

MM Kamrava 1 , L Tran 2 and JL Hall 3
1West Coast IVF Clinic, 2LA Center for Embryo Implantation, 3UCLA, the Geffen School of Medicine. USA

Full article: Hysteroscopy Newsletter

Prof. Jacques Hamou revolutionized hysteroscopy…. by Rahul Manchanda

Prof. Jacques Hamou revolutionized hysteroscopy. He built a scope of 5 mm, which carried a rod lens of 4 mm of improved visual optics and guided the distension media to the cavity. This eventually led to “ the traditional technique”, which involved a vaginal speculum, a tenaculam; often-cervical dilatation was necessary, which meant that the whole had to be done with Anaesthesia and in a operating theatre. Which necessitated
a longer hospital stay, greater discomfort and expense. Liquid media and co2 were used.

In early 1990 and onwards, several improvements were introduced. The major one,
diameter of the scope was reduced to 2mm,by Bettochi without compromising the visibility and quality of work. The no touch technique did away with the speculum, the tenaculum, need for dilatation and operating theatre. Procedures could be carried out in the OPD, suddenly making it a hugely popular device to diagnose, plan further surgery and carry out a variety of extensive surgical procedures. The instrument has evolved from a diagnostic tool to one where treatment can be carried out, using isotonic solution and in a out patient setting.

It is not possible to forecast when the procedure will reach its full potential or what the “potential” is. It is essential for both the scientists and doctors to strive to go t


hat little further.

profile_56baf8a6aea31 It is important that hysterocopists all over the world keep in touch with each


other so that these latest improvements and advances can be shared and translated into benefits for the patient.

Rahul Manchanda & Prabha Manchanda

Dysmorphic Uterus

DismorphycThe new classification system of Müllerian anomalies developed by the ESGE/ESHRE CONUTA working group has dedicated a specific interest to those uteri, named “dysmorphic”, characterized by a normal outline but with an abnormal lateral wall’s shape of the uterine cavity ( i.e. T-shaped uterus and tubular-shaped/infantilis uteri). These uteri are associated with infertility and pregnancy loss and in the previous
American Fertility Society classification were included in class VII and mainly related to
diethylstilbestrol-related (DES) exposure. However clinical experience has shown that
these uteri are more common than expected, mostly diagnosed in young infertile patients with no history of DES exposure.

Recently, Dr. Attilio di Spiezio Sardo has developed a new outpatient minimally invasive
technique yielding an increase in volume and an improved morphology of both tubular
uterine cavities and T-shaped (Hysteroscopic Outpatient Metroplasty To Expand Dysmorphic Uteri: the HOME-DU technique). The technique, performed under conscious sedation, involves that two incisions of 3–4 mm in depth are made with a 5- Fr bipolar electrode along the lateral walls of the uterine cavity in the isthmic region, followed by additional incisions placed on the anterior and posterior walls of the fundal region up to the isthmus.

Hysteroscopy and Fertility: Uterine septum


It is difficult to determine the incidence of congenital uterine malformations in the general population because most affected women do not experience reproductive problems. The incidence has been calculated to be 1 or 2 per 1000 women and as
high as 15 per 1000 women. Some studies have reported a 12% incidence.

A uterine septum is believed to develop as a result of failure of resorption of the tissue connecting the two paramesonephric (müllerian) ducts prior to the 20th embryonic week. While the arcuate uterus represents the mildest form of resorption failure, unlike the septum, it is not considered clinically relevant. Septate uteri have a spectrum of configurations including incomplete/partial septate to complete septate uterus.

High-quality studies on the clinical impact of the septate uterus in fertile women are lacking but the condition seems to be associated with adverse pregnancy outcomes (increased miscarriage, preterm delivery and breech presentation rates). The effect of a septum on fertility is less clear. The prevalence of the septate uterus in the infertile population is similar compared with a population of patients who underwent investigation of the uterus for other indications (e.g. sterilization, pelvic pain and abnormal bleeding). This suggests that a uterine septum does not play a role in the process of conception as such.

Not only the septate uterus, but also the arcuate uterus is characterized by a certain degree of indentation of the fundus into the uterine cavity. The arcuate uterus is a variation of normal uterine anatomy and is not associated with adverse pregnancy outcomes or infertility. Due to the differences in pregnancy outcome, correct diagnosis of both conditions is essential. In a recent study, however, the agreement on the diagnosis of the septate uterus based on hysteroscopy was demonstrated to be poor with differentiation between a septate and arcuate uterus appearing to be especially difficult.

One of the larger studies compared 153 women with all types of uterine anomalies to a control group of 27 women with a normal uterus. In the 33 women diagnosed with a septate uterus there was a higher incidence of infertility compared with controls (21.9% vs 7.7%); however, this difference did not reach statistical significance. One study evaluated infertility in women with müllerian anomalies compared with those with external genital anomalies and a normal uterus. When all other causes had been excluded, infertility was not seen more frequently in the 17 women with a septate uterus. In another study, 33 women were followed prospectively for 24 months after hysteroscopic diagnosis of arcuate and septate/bicornuate uteri. There was no difference in cumulative pregnancy rates or monthly fecundity when compared with those with a normal-shaped cavity. In a more recent study, 92 women with a septate uterus were identified at laparoscopy and hysteroscopy performed for miscarriage or infertility (primary or secondary) and compared with 191 women found to have a normal uterus. Primary infertility was less common in those with a septate uterus compared with
controls (43.5%vs 64.9%, P1⁄4.001).

However, in a meta-analysis evaluating the effect of congenital uterine anomalies on reproductive outcomes, septate uterus was the only anomaly that was associated with a significant decrease in the probability of natural conception when compared with controls (relative risk [RR] 0.86, 95% confidence interval [CI] 0.77–0.96).

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