During this session, Dr Elias Tsakos, FRCOG, Medical Director of Embryoclinic – Assisted Reproduction Clinic in Thessaloniki explained the role of hysteroscopy in miscarriage management.
Miscarriage is defined as the loss of pregnancy before 20 weeks of gestation. It is the most common form of pregnancy loss, occurring in approximately 1 in 4 pregnancies. The rate of miscarriage increases with a woman’s age, and it varies among different age ranges. For women in their early 30s, the rate may be as low as 10-15%, while for women in their 40s, it could be as high as 30%. In the mid-40s, the rate can reach 50-70%. These rates refer to women conceiving naturally or using their own eggs in fertility treatments. However, even with egg donation, there is still a higher association of miscarriage with age, although the rate is lower compared to using their own eggs. It’s important to note that around 80% of miscarriages occur within the first trimester.
Various factors contribute to miscarriages, and their significance differs based on a woman’s age. In younger women, chromosomal anomalies are more common, while uterine anatomy anomalies play a more significant role. Thrombophilia, hormonal factors, immunology factors, and metabolic factors are also potential contributors. Sometimes, there can be a combination of these factors, and it requires investigation to identify them accurately.
Hysteroscopy is a simple and cost-effective procedure that allows direct visualization of the uterine cavity. With a hysteroscope, which is a small-diameter instrument, we can examine the uterine cavity by inserting it through the cervix. No incisions or cuts are required. The hysteroscope typically includes a camera, a flashlight, and a working channel for operative hysteroscopy if necessary.
There are two types of hysteroscopy: diagnostic and operative. Both can be performed in an outpatient clinic. There has been much discussion about where to perform hysteroscopy, ranging from general anaesthesia in a hospital setting to performing it without anaesthesia or with mild sedation. We need to strike a balance between minimal access and outpatient procedures while ensuring patient comfort and safety.
In my practice, I often use anaesthesia to ensure the patients have a better experience.
The term “minimally invasive” is used to describe hysteroscopy, as there are no incisions or scars involved. It is considered a standard of care and offers a one-stop approach to diagnosis and treatment. However, there is debate about how much can be treated in the outpatient setting or in an IVF clinic. I believe we should carefully select patients and consider the complexity of the surgery before performing hysteroscopic interventions. In some cases, the diagnostic part can be done in the outpatient setting, while the operative part may require a hospital setting.
The applications of hysteroscopy include restoring the anatomy of the uterine cavity, diagnosing and treating congenital uterine anatomical pathologies, and assessing unexplained infertility or recurrent miscarriages. Additionally, hysteroscopy can be used to manage miscarriages. Instead of blindly evacuating the products of a miscarriage, hysteroscopy allows for the removal of retained products while evaluating the uterine cavity, eliminating the need for a separate diagnostic hysteroscopy.
During the hysteroscopic assessment, we may encounter normal and pathological findings. With the advancement of ultrasound technology, we can often suspect pathology before the hysteroscopic procedure and prepare accordingly. If a polyp, fibroid, or septum is found, it can be treated during the hysteroscopy, depending on the setting and circumstances. Tissue biopsies can also be performed for the safety of our patients, especially those in their mid to late 40s or early 50s.
Overall, hysteroscopy offers valuable diagnostic and therapeutic benefits in the management of various uterine conditions.
Probably, you are aware that the law now in Greece allows performing fertility treatment and IVF for women up to the age of 54, just under 54. This means we are dealing with women who may potentially have malignancy. Therefore, we must recognize the value of hysteroscopy in order to eliminate the risk of malignancy.
In my practice, I encounter two to three cases of uterine malignancy every year. You can imagine the consequences if such cases were missed and the patients proceeded with IVF, only to have the diagnosis delayed during pregnancy and delivery. So, the importance of hysteroscopy extends beyond the success of IVF to ensure the safety of our patients.
The main pathologies we treat via hysteroscopy include fibroids, congenital anomalies, polyps, and adhesions. There are various types of hysteroscopes and energy sources available, offering a wide range of options and techniques. Over the past 20 years, we have gained extensive experience in the field of hysteroscopy.
Hysteroscopy has been proven to improve fertility, not only in operative procedures but also in diagnostic hysteroscopy. Our own studies at Embryoclinic, have shown that even with normal pathology, hysteroscopy can increase the chance of conception by about 10%.
A new application of hysteroscopy is the targeted removal of products of conception. The team at Embryoclinicn are enthusiastic about this approach due to the amazing evidence in the literature. Instead of a blind procedure, it is now possible to perform a targeted removal with better precision, minimal injury to the endometrium, and simultaneous evaluation of the uterus. This approach provides multiple benefits, including a high success rate, low complication rate, high live birth rate, and low pregnancy loss rate.
Studies demonstrate the significant advantages of hysteroscopic management compared to the standard blind surgical evacuation of miscarriages currently practised worldwide.
In conclusion, miscarriages can, unfortunately, occur following spontaneous or artificial conception. Hysteroscopy plays a valuable role in diagnosing and treating anatomical anomalies associated with miscarriage. It can also be used as a management tool for miscarriages, resulting in improved pregnancy rates, reduced complications, decreased re-operation rates, and decreased bleeding.- Questions and Answers