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Chapter 11b
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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Polyps
Endometrial or uterine polyps are soft, fingerlike growths which develop in
the lining of the uterus (the endometrium). They develop because of excessive
multiplication of the endometrial cells, and are hormonally dependent , so that
they increase in size depending upon the estrogen level. They can usually be
detected on an ultrasound scan if this is done mid-cycle, when estrogen levels
are maximal, but are easily missed if the scan is not done at the right time of
the menstrual cycle. Polyps are an uncommon but important cause of infertility,
because they can easily be removed during hysteroscopic surgery.
Fibroids
While the commonest problem found in the uterus is a fibroid (myoma), this is
rarely a cause of infertility, and is usually an incidental finding of little
importance. Fibroids are common benign smooth muscle tumors which arise in the
wall of the uterus, and may be single or multiple. About 25% of all women over
the age of 35 have fibroids. Most fibroids develop in the wall of the uterus
(intramural ) or protrude outside of the uterine wall (subserous fibroids), and
these can usually be left alone, since they do not hinder fertility, and neither
do they cause problems during the pregnancy. In fact, unnecessary surgery to
remove the fibroid often causes more harm than good. This surgery often creates
adhesions, which causes the tubes to get blocked. However, if the fibroids are
very large, they may need surgical removal, and this procedure is called a
myomectomy. Some doctors give an injection of a GnRH analog prior to surgery in
order to shrink the fibroid and make surgery technically easier. When performed
by an expert, it is a safe and effective procedure which can be accomplished
with minimal blood loss. However, sometimes because of uncontrollable bleeding
the surgeon may be forced to remove the entire uterus (a procedure called a
hysterectomy), and this is obviously a disaster for the infertile woman! The
standard technique for removing a fibroid is through open surgery (laparotomy).
It is now also possible to remove fibroids through the laparoscope, but
laparoscopic myomectomy does not allow for optimal reconstruction of the uterus.
Submucous fibroids are an important cause of infertility, because they interfere
with implantation of the embryo, by acting as a foreign body. These are best
removed by an operative hysteroscopy. While surgery can remove the fibroid, it
can recur again, and most doctors advise the patient to try to conceive as soon
as possible after surgery.

Fig 2. Schematic showing a submucous fibroid; and a
subserous fibroid compressing the right fallopian tube
Fibroids may grow larger during the pregnancy, but usually pregnancy and
delivery are uneventful. In rare cases, after a myomectomy, uterine rupture may
occur during pregnancy or delivery, and this complication may result in severe
blood loss, fetal loss and even maternal death. Because of the potential for
catastrophic results, it is recommended that women have cesarean deliveries in
the following circumstances: 1) when the myomectomy involved full-thickness
incision of the uterine wall or multiple deep uterine incisions or 2) when
myomectomy was complicated by infection which may have weakened the uterine wall
or 3) when there is doubt regarding the adequacy or extent of the uterine
repair.
The uterus was often a neglected organ in the infertility workup, partly
because we did not have the tools to study it properly. Hysteroscopy,
hysterosalpingography and vaginal ultrasound are all complementary procedures
for evaluating the uterine cavity in the infertile woman. The HSG is good for
looking for polyps, adhesions and septa which appear as "filling
defects" on the X-ray. However, careful radiologic technique is a must.
Vaginal ultrasound is excellent for detecting submucosal fibroids or polyps,
which can be missed on hysteroscopy and HSG. Of course, the major advantage of
hysteroscopy is it offers the chance of treating the problem as well!
We are now also developing newer techniques to study the uterus. One of our
major areas of ignorance today is the complex process of embryo implantation. It
is obvious that the endometrium has a key role to play in this process, in which
the embryo has to appose and attach itself to the maternal endometrium and
invade into it. The normal endometrium contains cell adhesion proteins called
integrins, which allow the embryo to interact with it. Studies have shown that
the endometrium of some infertile women is deficient in some of these integrins,
and this deficiency may be responsible for failure of the embryo to implant
successfully. Thus, testing the endometrium for beta integrin can be a useful
marker for uterine receptivity. This test involves doing an endometrial biopsy
at a specific point in the menstrual cycle, and evaluating this with special
staining techniques, but is only available on a research basis so far.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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