Chapter 11a
Hysteroscopy

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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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:

1. submucous (internal) fibroids
2. scarring (adhesions or synechiae)
3. endometrial polyps
4. 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 scraping of the inside of the uterine cavity) after the hysteroscopy and send the endometrial tissue for pathologic examination.

Operative hysteroscopy

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.

A very exciting 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 rarely occur 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.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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