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1. Fertility .. Good ovum, Good Sperm Good embryo Patent and functioning tube Good Uterine cavity Receptive Endometrium 17/08/2014 CGISAR 1

2. Hysteroscopic Surgeon 17/08/2014 CGISAR 2

3. Content Diagnostic Hysteroscopy Submucous Fibroid Uterine septum Intrauterine Adhesions Endometrial Polyp Proximal Tubal Block Prior to ART Endometrial Scratching 17/08/2014 CGISAR 3

4. Introduction Uterine factors can be found in only 2 to 3% of infertile women, but intrauterine lesions are much more common in this setting (40–50%) These lesions can compromise spontaneous fertility as well as reduce pregnancy rates in assisted reproduction . Published observational studies suggest increased pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum, or intrauterine adhesions, which can be found in 10% to 15% of women seeking treatment for subfertility . 17/08/2014 CGISAR 4

5. Diagnostic Hysteroscopy Evaluation of the uterine cavity is a basic step in female infertility workup. Transvaginal sonography Hysterosalpingography and are most commonly used for this purpose. Hysteroscopy, however, is considered the gold standard for diagnosis of intrauterine lesions .  17/08/2014 CGISAR 5

6. American Society for Reproductive Medicine (ASRM) Hysteroscopy is the definitive method for the diagnosis and treatment of intrauterine pathology. Costly and invasive method for uterine cavity evaluation, it should be reserved for further evaluation and treatment of abnormalities defined by less invasive methods such as HSG and sonohysterography [ Fertility and Sterility, vol. 98, no. 2, pp. 302–307, 2012 ] 17/08/2014 CGISAR 6

7. Diagnostic Hysteroscopy Normal 2D/3D USG/ HSG Unexplained infertility Uterine anomaly Prior to IVF Repeated IVF Failures Suspected endometrial pathology Recurrent abortion Abnormal uterine bleeding In combination with laparoscopy and TVS Gives complete diagnosis 17/08/2014 CGISAR 7

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11. Submucous fibroid According to the ASRM (2008) - intracavitary myomas and submucous myomas having at least 50% of their volume within the uterine cavity. In infertile women and those with recurrent pregnancy loss, myomectomy should be considered only after a thorough evaluation has been completed. 17/08/2014 CGISAR 11

12. Type0 & 1 hysteroscopic myomectomy Types of submucous fibroids 17/08/2014 CGISAR 12

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14. Meta-analysis- Submucous fibroid Pritts et al. 2009 - studies regarding the effect of fibroids on fertility and of myomectomy in improving outcomes. They concluded that fertility outcomes are decreased in women with submucosal fibroids Removal seems to confer benefit in terms of pregnancy rates. 17/08/2014 CGISAR 14

15. RCT- Submucous fibroid.. T. Shokeir , et al  Fertility and Sterility, vol. 94, no. 2, pp. 724–729, 2010 Prospective randomized matched control trial, 215 women with unexplained primary infertility and with ultrasonographically diagnosed submucous fibroids were enrolled. Women in the study group had a better possibility of becoming pregnant after hysteroscopic myomectomy . No difference in pregnancy rates was observed according to fibroid size, number, and location in both groups. 17/08/2014 CGISAR 15

16. Uterine Septum Septal resection improves outcome in BOH Its role in Infertility ? Current data does not give its causal role 17/08/2014 CGISAR 16

17. Metroplasty Most studies of metroplasty for a septate uterus combine women with recurrent miscarriage and infertility, and no study has been published that randomizes infertile women to treatment versus no treatment. For this reason controversy exists as to whether infertile women should undergo metroplasty   C. R. Kowalik , M. Goddijn , M. H. Emanuel et al., “ Metroplasty versus expectant management for women with recurrent miscarriage and a septate uterus,” Cochrane Database of Systematic Reviews, no. 6, Article ID 17/08/2014 CGISAR 17

18. Uterine Septum Some recommended surgery and some not but randomized data is lacking. Pabuccu et al found 41% spontaneous pregnancy rates after septal resection in patients with unexplained infertility with septum. Long standing infertility with septum and otherwise unexplained. 17/08/2014 CGISAR 18

19. Hysteroscopic septal resection Microscissors , electrorosurgery , fiberoptic laser energy. 17/08/2014 CGISAR 19

20. Metroplasty . Reproductive outcomes are improved after hysteroscopic resection. Fedele et al evaluated the reproductive outcome after hysteroscopic metroplasty in 31 women with infertility and 71 women with miscarriage, and reported a cumulative pregnancy rate of 89% at 36 months for patients with complete septum and 80% for those with partial septum 17/08/2014 CGISAR 20

21. Reproductive Outcome following Hysteroscopic Monopolar Metroplasty : An Analysis of 203 Cases Ensieh Shahrokh Tehraninejad Int J Fertil Steril . 2013 Oct-Dec; 7(3): 175–180. Evaluate the reproductive outcome of women with history of infertility or recurrent miscarriage following hysteroscopic septum resection  Term deliveries increased significantly from 2.5 to 33.5%. 17/08/2014 CGISAR 21

22. Metroplasty Laparoscopic guidance frequently is used during hysteroscopic metroplasty to reduce the risk of uterine perforation. IUD insertion for 3 months with estrogenisation is only recommended for complete or wide septa. 17/08/2014 CGISAR 22

23. Intrauterine Adhesions Intrauterine trauma resulting from vigorous endometrial curettage After multiple myomectomy,septum resection. Associated  with  RPL. The severity of adhesions may range from minimal to  complete 17/08/2014 CGISAR 23

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27. ESGE Grade 3&4 require electrosurgical adhesiolysis and pregnancy rates are 20-40% Post op IUD and estrogen is adminsitered after electrosurgical adhesiolysis . Complication rates are also high 17/08/2014 CGISAR 27

28. T sahped uterus Pts with TB Narrow constricted,T shaped cavity Decreased menstrual flow and amenorrhoea Metroplasty fundal and lateral Post op estrogen and IUD Better pregnancy rates with IVF ET 17/08/2014 CGISAR 28

29. Cochrane review Hysteroscopic myomectomy might increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive. Hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate J. Bosteels , “Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities,” Cochrane Database of Systematic Reviews, no. 1, Article ID CD009461, 2013 17/08/2014 CGISAR 29

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32. Hysteroscopic tubal cannulation appears to be more effective than fluorosocpic guided canulation or open microsurgical repair or IVFET. 17/08/2014 CGISAR 32

33. Endometrial Polyps Localized overgrowths of endometrium . Polyps can distort the endometrial cavity, may have a detrimental effect on endometrial receptivity, and increase the risk of implantation failure . The gold standard for diagnosis is hysteroscopy and hysteroscopic polypectomy remains the mainstay of management. 17/08/2014 CGISAR 33

34. Endometrial Polyp 17/08/2014 CGISAR 34

35. Endometrial polyps A recent Cochrane review tried to assess the effect of hysteroscopic polypectomy on the results of intrauterine insemination (IUI). Apparently, the hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy compared to diagnostic hysteroscopy and polyp biopsy only (OR 4.4, 95% CI 2.5 to 8.0, and ).(J. Bosteels ) Implantation and clinical pregnancy rates were statistically significantly increased after hysteroscopic polypectomy in a group of women with recurrent implantation failure after IVF. I.( Stamatellos ) In conclusion, it appears that polypectomy prior to IUI or IVF (even I cases with previous implantation failure) increases the chances of pregnancy. 17/08/2014 CGISAR 35

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37. For the infertile patient with a polyp, surgical removal is recommended to allow natural conception or assisted reproductive technology a greater opportunity to be successful (Level A). 17/08/2014 CGISAR 37

38. Hysteroscopy prior to ART A systematic review comparing the outcome of IVF treatment performed in patients who had outpatient hysteroscopy. The results of five studies showed evidence of benefit from outpatient hysteroscopy in improving the pregnancy rate in the subsequent IVF cycle . F. Lorusso , O. Ceci , S. Bettocchi et al., “Office hysteroscopy in an in vitro fertilization program,”Gynecological Endocrinology, vol. 24, no. 8, pp. 465–469, 2008 . 17/08/2014 CGISAR 38

39. Hysteroscopy prior to 1 st IVF A systematic review and meta-analysis Jyotsna Pundir   et al Reproductive BioMedicine Online Volume 28, Issue 2 , Pages 151-161, February 2014 Hysteroscopy in asymptomatic woman prior to their first IVF cycle was found to be associated with improved chance of achieving a pregnancy and live birth when performed just before commencing the IVF cycle . Robust and high-quality randomized trials to confirm this finding are needed to further guide clinical practice. 17/08/2014 CGISAR 39

40. Currently, there is evidence that performing hysteroscopy before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles ( Bosteels et al, 2010  and  El- Toukhy et al, 2008 ). However, recommendations regarding the efficacy of routine use of hysteroscopy prior to starting the first IVF treatment cycle are lacking . 17/08/2014 CGISAR 40

41. Hysteroscopy prior to ART Another recent study included 157 women with a history of recurrent IVF failures (two or more) who underwent hysteroscopy (diagnostic or operative, as appropriate) to evaluate the endometrial cavity. Abnormal hysteroscopic findings were found in 44.9% of the patients in this study and 75 women (48.1%) became pregnant following hysteroscopy . Of these pregnancies, 36 occurred in women with corrected endometrial pathology, the majority of which was polyp. P. Cenksoy et al Archives of Gynecology and Obstetrics, vol. 287, no. 2, pp. 357–360, 2013. 17/08/2014 CGISAR 41

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43. Endometrial scratching improves IVF pregnancy rate BMJ  2013; 347 Endometrial scratching involves causing intentional damage to the endometrium through biopsy or curettage. An association between endometrial scratching and an increased chance of pregnancy was first described a decade ago, although the underlying mechanism remains unknown. 17/08/2014 CGISAR 43

44. The new study involved 158 women who had previously had unsuccessful courses of reproductive treatment and were taking an oral contraceptive pill directly before treatment. The women were randomly allocated to endometrial scratching with a pipelle de Cornier or a sham procedure 7-14 days before core ovarian stimulation was started. Thirty nine of 79 women (49%) in the endometrial scratching group and 23 of 79 (29%) in the control group achieved a clinical pregnancy (risk ratio 1.83 (95% confidence interval 1.13 to 2.97)). There were 33 live births in the scratching group (42%) and 18 (23%) in the control group (risk ratio 1.7 (1.13 to 2.56) 17/08/2014 CGISAR 44

45. Endometrial scratching Improves the clinical pregnancy rate in women undergoing assisted reproductive treatment, new research shows. A Cochrane Library systematic review published in 2012 concluded that the technique doubled the chance of pregnancy and live birth after in vitro fertilisation (IVF) treatment but said that more research was needed. 17/08/2014 CGISAR 45

46. Conclusion Hysteroscopy in the management of the infertile female remains under debate . The procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women . 17/08/2014 CGISAR 46

47. Conclusion The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome observational studies suggest a benefit for resection of submucosal leiomyomas , adhesions, and endometrial polyps in increasing pregnancy rates. More randomised controlled studies are needed to substantiate the effectiveness  17/08/2014 CGISAR 47

48. Conclusion Hysteroscopy before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles Endometrial scratching Improves the clinical pregnancy rate in women undergoing assisted reproductive treatment. 17/08/2014 CGISAR 48

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