During this event, Dr Harry Karpouzis, Founder and Scientific Director of IVF Pelargos Fertility Group, shared valuable insights on how hysteroscopy can significantly influence your IVF success. He explained the latest advancements in diagnostic and operative hysteroscopy and its essential role in pre-IVF evaluation.
Dr Karpouzis covered key procedures, including resection of fibroids, polyp removal, treatment of intrauterine adhesions, septum removal, endometrial scratching, targeted biopsies for immunological testing, chronic endometritis, endometriosis, and assessment of the implantation window.
This session provided a comprehensive overview of how hysteroscopy helps optimise the uterine environment for embryo implantation.
Hysteroscopy plays an increasingly important role in the preparation phase before in vitro fertilisation (IVF), particularly for patients who have experienced implantation failure or unexplained infertility. In this presentation, Dr Harry Karpouzis, Founder and Scientific Director of IVF Pelargos Fertility Group, explained how modern hysteroscopy has evolved into a highly precise diagnostic and therapeutic tool and how it can support better IVF outcomes in selected patients.
Dr Karpouzis explained that hysteroscopy is a minimally invasive surgical procedure that allows doctors to look directly inside the uterine cavity. A small camera is inserted through the cervix into the uterus, enabling visual assessment of the endometrium, the lining of the womb, under direct vision.
One of the key advantages of hysteroscopy is that it can be both diagnostic and therapeutic at the same time.
We can see the cavity and treat problems during the same procedure.
Dr Karpouzis explained. Depending on the situation, hysteroscopy can be performed as an outpatient procedure without anaesthesia or, when more complex treatment is required, under sedation or anaesthesia.
There are two main types of hysteroscopy: diagnostic and operative. Diagnostic hysteroscopy is used to assess the uterine cavity, while operative hysteroscopy allows treatment of abnormalities found during the examination.
Through operative hysteroscopy, doctors can remove uterine polyps, treat submucosal fibroids, correct uterine septa present from birth, and manage intrauterine adhesions such as those seen in Asherman’s syndrome. Dr Karpouzis noted that scar tissue caused by previous surgeries, infections, or pregnancy terminations can lead to a thin endometrium and reduced implantation potential, and hysteroscopy allows these issues to be addressed directly.
A key question discussed was whether hysteroscopy should be performed routinely for all IVF patients. Dr Karpouzis referred to recent meta-analyses of randomised studies showing that hysteroscopy improves clinical pregnancy and live birth rates in women with recurrent implantation failure.
However, when hysteroscopy is performed routinely in all patients without a history of implantation failure, the evidence is mixed and does not show a clear benefit.
The answer from research is no, not everybody needs a hysteroscopy.
He explained. Instead, the decision must balance the risk of missing subtle abnormalities against the cost and invasiveness of the procedure.
A major focus of the presentation was chronic endometritis, a persistent inflammation or infection of the endometrial lining. Dr Karpouzis explained that chronic endometritis is often asymptomatic and may be associated with recurrent implantation failure, unexplained infertility, and recurrent miscarriage.
Hysteroscopy is considered the gold standard for diagnosing chronic endometritis because it allows direct visual assessment of the uterine cavity. Other tests, such as hysterosalpingography (HSG) or ultrasound, may evaluate the uterus and fallopian tubes but cannot reliably detect subtle inflammatory changes or mild scar tissue.
Identifying chronic endometritis during hysteroscopy requires specific expertise. Dr Karpouzis emphasised that reproductive medicine knowledge is essential, as the condition can present in many different ways. Possible hysteroscopic signs include micropolyps, pale or thickened endometrium, red spots, or a “strawberry-like” appearance with red and white areas.
When these signs are present together, diagnostic accuracy can be high, but often only one or two features are visible. For this reason, targeted biopsies taken under direct vision are essential. Blind biopsies may miss affected areas and lead to false-negative results.
In addition to histological examination, modern molecular tests can identify the exact microorganisms responsible for chronic endometritis. Dr Karpouzis described next-generation sequencing (NGS) tests that analyse the endometrial microbiome and identify bacteria such as E. coli, Mycoplasma, or other pathogens. These tests allow clinicians to prescribe targeted antibiotic treatment rather than empirical therapy.
Endometrial scratching was another important topic discussed. Dr Karpouzis explained that recent systematic reviews show that scratching performed during hysteroscopy can improve live birth rates in women with recurrent implantation failure. However, no benefit has been demonstrated in women undergoing their first IVF cycle without a history of implantation failure.
He also discussed a possible immunological mechanism, explaining that local endometrial injury may stimulate cytokine release and mobilisation of uterine natural killer cells. In some patients, the problem is not over-activation of these cells but insufficient mobilisation, and endometrial scratching may be beneficial in this specific group.
Endometrial scratching is typically performed in the luteal phase of the cycle before embryo transfer. Dr Karpouzis noted that combining scratching with hysteroscopy allows direct cavity assessment, treatment of abnormalities, and targeted scratching in a single procedure, avoiding the need for multiple interventions.
Technological advances have significantly improved hysteroscopy. Smaller and flexible hysteroscopes, high-definition cameras, and 3D imaging have reduced discomfort and increased diagnostic accuracy. Dr Karpouzis also discussed the future role of artificial intelligence, which may help identify subtle lesions that can be missed even by experienced clinicians.
In selected cases of severe Asherman’s syndrome or persistent thin endometrium unresponsive to surgery, hysteroscopy may also be combined with experimental approaches such as stem cell treatment. In these cases, stem cells are injected under the endometrium to improve thickness and receptivity.
Hysteroscopy can also assist in difficult embryo transfer cases. Previous cervical procedures, false passages, or anatomical changes may make embryo transfer challenging. By visualising the cervical canal, hysteroscopy can function as a mock transfer, helping clinicians plan the safest and most effective transfer approach.
In conclusion, Dr Karpouzis emphasised that hysteroscopy is a powerful tool for improving IVF outcomes in selected patients, particularly those with recurrent implantation failure. It should be performed by specialists with expertise in both minimally invasive surgery and reproductive medicine.
Hysteroscopy remains the gold standard for diagnosing chronic endometritis, allows targeted biopsies, and is diagnostically superior to ultrasound, HSG, or HyCoSy for detecting subtle intrauterine abnormalities. When combined with molecular testing and other emerging technologies, hysteroscopy offers a comprehensive approach to optimising the uterine environment before IVF.
It could be. I don’t know your age, but 2 of the embryos were of very good quality, so they had a good chance of being chromosomally normal, especially if you are at a good age. However, they failed. By definition, you now fall into the category of recurrent implantation failure.
If you are under 35, that’s considered a good age. If you decide to proceed again, you are in the recurrent implantation failure group. PGT-A should be considered because you’ve already had 3 failed transfers, 2 with very good embryos.
If you create a chromosomally normal embryo and know that it’s viable before transfer, it’s reasonable to check for other factors. Hysteroscopy is one of those steps. It can help ensure nothing is being missed, such as a chronic infection or minor scar tissue. So yes, I would advise doing a hysteroscopy before transferring another embryo.
If you’re taking the maximum dose of estrogen correctly and the endometrium is not thickening, you need to investigate further. A hysteroscopy is needed to look inside and check if there’s a problem. If a problem is found, it can be treated, allowing for better thickness in the future.
This is a good question. Generally, studies show that estrogen should be taken for 12 to 18 days before starting progesterone. We can’t keep prolonging estrogen indefinitely, as it might affect the implantation window.
If the endometrium does not reach the desired thickness after 18 days of high-dose estrogen, it’s unlikely to grow significantly more. In that case, we need to investigate the reason.
You can increase the dose, give it more time, and push things slightly beyond day 12, but eventually, if the thickness is not achieved, it may be better to cancel the transfer and check what’s happening rather than compromise your embryos.
Endometritis is something that first needs to be seen with the camera. If you take a biopsy and send it for a normal histology, endometritis may not be shown. It needs a specific type of histology using CD138. When CD138 is used and plasma cells are seen, this shows signs and suspicion of endometritis.
The most accurate way to diagnose not just general endometritis but also its cause—whether it’s Ureaplasma, Mycoplasma, E. coli, or something else—is through molecular tests like NGS tests: the ALICE or EMMA test, or other similar ones. These tests identify the specific cause and tell you which antibiotics to use. If you don’t know the cause, then a triple antibiotic scheme is often used to cover everything. But when you know the exact cause, you can target it specifically and treat it.
If we do a hysteroscopy and see a chronic infection, you will take antibiotics. If we see a deranged microbiome, you might need probiotics. If we see scar tissue during hysteroscopy, we will treat it, because we now have a reason. If nothing works and the endometrium remains thin, we have some ways to try to improve it, like PRP or stem cells, as discussed before.
No. CD138 is a marker used to identify infection and inflammation. It shows the possibility and high chance of endometritis.
The ALICE and EMMA tests are used to show the microbiome and causes of chronic infection inside the endometrium. They can be done as outpatient procedures without hysteroscopy. But when done blindly, you might miss some findings because you don’t know exactly where to take the sample from. You may take a sample from areas that don’t show the chronic infection.
It’s possible to do the test without hysteroscopy, but it is always better, if possible, to do it together with hysteroscopy. It’s not only about endometritis. You may also see other issues that can be treated at the same time, like a small polyp, scar tissue, or something else. Additionally, you can take targeted biopsies using the camera. In an outpatient setting, you usually insert a pipelle and take a scraping. Most of the time, this shows something, but it is not targeted.
It’s not only about hysteroscopy. In my personal opinion, you need to do it. Five miscarriages are recurrent miscarriage to a significant degree. An ectopic is different, but failed transfers are recurrent implantation failure. This needs a thorough investigation.
It would be a very good idea, after all this history, to know the chromosomes of the embryo before transfer. If you keep transferring embryos without knowing their chromosomes, they may fail again, and you won’t know the reason. You might investigate everything else, but in the end, the issue may be the embryo. If you manage to achieve a chromosomally normal embryo, then all that is needed is thorough testing.
You need to investigate thrombophilia, blood clotting disorders. You also need to investigate with hysteroscopy for endometritis and similar issues. I don’t see how a hysteroscopy can be damaging. It’s a very straightforward procedure in the right hands. You go home the same day.
You can also combine hysteroscopy with tests related to immunology. Five miscarriages may require steroids, intralipids, Plaquenil, or additional progesterone, depending on the case.
The most common reason for miscarriage is chromosomes. I don’t know your age, but at age 40 to 42, the risk of miscarriage can reach 30%. At age 44, even in a spontaneous pregnancy, the risk can be around 50%. The reason is chromosomes.
If you have done tests for blood clotting and thrombophilia, that’s good, you’ve ruled those out. If you’ve had a hysteroscopy and nothing was found, that’s also good. But have you checked immunology? That can be important.
There are tests, either blood tests or endometrial tests. At our clinic, we prefer endometrial tests to check local immunity—natural killer cells, cytokines, and other factors. This helps personalise the treatment according to the problem.
It’s a nice test. We are planning to introduce it as well. More or less, it does the same job as EMMA and ALICE. EMMA and ALICE are usually done with samples from inside the endometrium, while the microbiome test you mention uses blood from the period. It has significant evidence behind it, so it’s a good test.
If it has come back negative, I usually say that when you choose a doctor who recommends a test, or you choose a specific test, trust it. I can’t say that EMMA/ALICE is better than Fertilys or not. They work in slightly different ways. EMMA analysis has been on the market longer, but I know about Fertilys and that it can sometimes show things even more thoroughly than EMMA and ALICE.
All of them do more or less the same job—identifying the same things in different ways. If you’ve done Fertilys, I wouldn’t repeat it just to find something new. Maybe the problem is hidden somewhere else.
Yes, if you are sure and know how to identify it, you don’t really need to have an NGS test. NGS will confirm the cause of the endometritis. Without it, you can say it’s endometritis, but you won’t know the cause. You might need to take a triple scheme of antibiotics to cover everything. In some units, even though there is not a lot of evidence, they use endometrial washing and similar methods. That’s the benefit of taking targeted biopsies. But sometimes, it is pretty obvious that there is endometritis. You can trust the doctor as long as he knows how to interpret it.
Yes, we have a very good acupuncturist at Pelargos IVF. She is from San Diego in the US and is quite experienced. We use it and have seen some good results. I’m not exactly sure how it works. It might help as stress relief, maybe as a placebo effect, or by creating a local inflammation. The mechanisms are not proven, but research shows it can sometimes improve endometrial thickness, implantation chances, or even the number of eggs. It will not cause harm. Especially if you are going through this process under stress, you have nothing to lose by combining it as an adjunct therapy. It is not to replace IVF but to be used together with it, possibly to help.
There is no conclusive evidence behind it, but some good studies show improvement, even if the mechanisms are not always clear.
Because if the endometrium is not getting thick with a good dose, we increase it a bit more to see if it will help. Otherwise, we will not know. That’s why we increased it.
You don’t have an obvious reason to do a hysteroscopy. The main thing is to create good embryos. At this age, you could also do PGT-A to see if you can get a chromosomally normal embryo. If not, at least try to get some embryos, which is not easy in this age group. If you do have a very good quality embryo, or only one, or a chromosomally normal one, then it’s very precious. I tell women in this age group that if you only have one embryo and time is running out, you don’t have anything to lose by checking with hysteroscopy, even if you don’t have a history of recurrent implantation failure or miscarriage. You might find something and regret not having done it.
Where is the scar issue? Is the scar inside the endometrium? Were the fibroids removed with hysteroscopy or laparoscopy? Given that you’ve had double surgery and fibroid removal, sometimes when fibroids are removed, the cavity is breached, spreading infection inside or outside the cavity. Fibroids can be combined with small fibroids inside the cavity, which are not always easy to see on ultrasound.
The first thing at your age is to manage to create some embryos because it’s not easy at all. If you manage to create some embryos and haven’t recently checked with hysteroscopy, I would check. If there is scar tissue inside the endometrium, it needs to be treated surgically. Sometimes results are not easy to get, but you need to try. If you have a recurrent fibroid or a small submucosal fibroid inside the lining, it needs to be removed. If the cavity is clear, scar tissue inside the muscle of the womb might not be so important, but at least have a diagnostic procedure to make sure we’re not missing anything.
It’s one of the reasons. At your age, an AMH like that is quite low. If it’s associated with a low antral follicular count, that means the number of eggs you’ll get, even with IVF, will be lower. An AMH of 0.43 means that for your age, you have fewer eggs than other women your age. Sometimes there’s no reason; it just happens.
Trying for two years is a prolonged period, so you need to go to the next step. With this AMH, IVF is the next step because the longer you wait, the AMH will go down, the number of follicles will go down, and egg quality will go down. Your chances will get lower. So, go to the next stage, first, get some eggs. The good thing is that you’re 36. Even a smaller number of eggs can get you pregnant.
How many eggs you get depends on how many follicles are in your ovaries. The more you get, the better. Create good embryos. As for hysteroscopy, it’s not obligatory or necessary for you, but it depends. If your doctor sees something during IVF or if the lining of the womb is not okay, if it has abnormal thickness, etc., then yes.
Not really. Since you have done all this testing, and since it was done with an endometrial biopsy, generally, no steroids do not cause defects.
First of all, things are difficult for IVF with own eggs at this age. I would first try to create some good embryos. You might also consider PGT-A, because most of the time, the issue is not finding embryos with normal chromosomes. If you don’t have a normal embryo, transferring anything won’t work.
So don’t go into hysteroscopy and everything else before making sure you have embryos. MRI would help to determine the fibroid position. If you couldn’t do an MRI, at least do a hysteroscopy before transfer to ensure fibroids are not protruding into the endometrium. If they are, they need to be removed.
If fibroids are close to the endometrium, it’s a conflicting issue; different doctors have different opinions, and evidence is not conclusive. We usually remove fibroids more than 5 cm or those mildly changing the cavity or very close to the cavity, especially if there was a failed transfer. But you need to balance surgery, delay, and time. Right now, time is not your friend. The first thing you need to do is create embryos.
I recommend it from someone whose job is to do acupuncture, who has a licence and has worked with fertility protocols and has experience with fertility. In fertility clinics—for example, at Pelargos, we have someone very experienced who works specifically with infertile patients. She applies specific protocols. We trust her and recommend her because she knows her job. Someone with a licence and fertility experience.
The scar tissue inside the cavity is called Asherman’s syndrome. It’s not easy to treat. You need to try to remove it surgically. Many times, even if you try to remove it surgically, it’s not possible, and the endometrium does not get thicker and has problems.
In some cases of persistent Asherman’s syndrome that has been treated surgically and is not recovering, we use stem cells together with PRP. These are used so that you can try to achieve some healthy endometrium and some thickness. But it’s not an easy situation when you have scar tissue inside the endometrium because of previous surgeries or similar causes.
The first thing you need to do is try to treat it because sometimes, after a successful surgical procedure, you can get to a healthy endometrium and see some thickness depending on the degree of scar tissue. If it is not getting better, in cases like that, sometimes even surrogacy is an option.
